=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134421712
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CANYON GATE MEDICAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2010
-----------------------------------------------------
Last Update Date | 12/02/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 330 S LOLA LN SUITE# 200
-----------------------------------------------------
City | PAHRUMP
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89048-0884
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-656-8855
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2929 N UNIVERSITY DR SUITE# 110
-----------------------------------------------------
City | CORAL SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33065-5081
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-751-0695
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING COORDINATOR
-----------------------------------------------------
Name | VERONICA COLON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 954-656-8855
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 936
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------