=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366127789
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ENKI MEDICAL CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/21/2023
-----------------------------------------------------
Last Update Date | 07/11/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3606 ALGONQUIN DR
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89169-3150
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-510-9587
-----------------------------------------------------
Fax | 702-920-7677
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4820 EL ESCORIAL DR
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89121-6805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-510-9587
-----------------------------------------------------
Fax | 702-920-7677
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | YUSIMI LOPEZ RAMOS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 702-510-9587
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------