=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033384896
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KID DOCTORS URGENT CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2008
-----------------------------------------------------
Last Update Date | 04/23/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4840 S FORT APACHE 101
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89147-7949
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-254-5437
-----------------------------------------------------
Fax | 702-367-1698
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4840 S FORT APACHE ROAD 101
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89147-7949
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-254-5437
-----------------------------------------------------
Fax | 702-367-1698
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ERIC DEURELL
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 702-450-5437
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207PP0204X
-----------------------------------------------------
Taxonomy Name | Pediatric Emergency Medicine (Emergency Medicine) Physician
-----------------------------------------------------
License Number | 2081
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------