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General NPI Number Information
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NPI Number | 1275183766
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Entity Type | Organization
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Legal Business Name | NOT APPLICABLE
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Dates
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Enumeration Date | 09/17/2019
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Last Update Date | 10/11/2020
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Provider Practice Location Address
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Address Line | 2008 HAMILTON LN
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City | LAS VEGAS
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State | NV
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Zip | 89106-4033
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Country | US
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Telephone | 702-900-1489
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Fax |
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Provider Business Mailing Address
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Address Line | 1820 FEATHERBROOK AVE
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City | NORTH LAS VEGAS
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State | NV
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Zip | 89031-5052
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Country | US
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Telephone | 702-900-1489
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Fax |
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | YVETTE JONES
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Credential |
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Telephone | 702-350-1060
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number |
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License Number State |
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