=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366141848
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CJ MEDICAL CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2023
-----------------------------------------------------
Last Update Date | 09/03/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 835 SOUTH BOULDER HIGHWAY #335
-----------------------------------------------------
City | HENDERSON
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89015-1739
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-551-4608
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 835 SOUTH BOULDER HIGHWAY #335
-----------------------------------------------------
City | HENDERSON
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89015-1739
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-551-4608
-----------------------------------------------------
Fax | 725-215-9309
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | CARLOS ENRIQUE JIMENEZ POZO
-----------------------------------------------------
Credential | APRN-CNP
-----------------------------------------------------
Telephone | 725-247-4519
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------