Healthcare Provider Details

I. General information

NPI: 1649873571
Provider Name (Legal Business Name): JD TOM VENTURES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2020
Last Update Date: 04/13/2021
Certification Date: 04/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1460 E CALVADA BLVD
PAHRUMP NV
89048-5822
US

IV. Provider business mailing address

9867 ANTELOPE CANYON AVE
LAS VEGAS NV
89147-7739
US

V. Phone/Fax

Practice location:
  • Phone: 702-904-0260
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DAVID HARDY
Title or Position: ADMINISTRATOR
Credential:
Phone: 702-904-0260