=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053880856
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STARK MEDICINE MCKAY KHURANA JEIDER PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2018
-----------------------------------------------------
Last Update Date | 03/28/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6600 W CHARLESTON BLVD STE 140
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89146-1067
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 725-246-1483
-----------------------------------------------------
Fax | 866-518-0781
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 840 S RANCHO DR STE 4-903
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89106-3837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-440-8840
-----------------------------------------------------
Fax | 866-518-0781
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TIMOTHY BENJAMIN JAMES JEIDER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 702-350-2906
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0804X
-----------------------------------------------------
Taxonomy Name | Child & Adolescent Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------