=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255645834
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEVADA CHOICE MED INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2010
-----------------------------------------------------
Last Update Date | 08/05/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3580 W 9000 S
-----------------------------------------------------
City | WEST JORDAN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84088-8812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-437-2824
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4075 S DURANGO DR STE 111-26
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89147-4163
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-437-2824
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | RICHARD D BROBYN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 877-437-2824
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 46D1024082
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------