=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265045884
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FIELD MEDICAL GROUP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2020
-----------------------------------------------------
Last Update Date | 08/24/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3017 W CHARLESTON BLVD STE 70
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89102-1928
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-957-8337
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3017 W CHARLESTON BLVD STE 70
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89102-1928
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-957-8337
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DELL JOHN NAVATA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 702-957-8337
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------