=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396994943
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CANYON GATE MEDICAL GROUP, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2008
-----------------------------------------------------
Last Update Date | 04/20/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9280 W SUNSET RD SUITE 426
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89148-4860
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-262-0124
-----------------------------------------------------
Fax | 702-262-0143
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2929 N UNIVERSITY DR SUITE 110
-----------------------------------------------------
City | CORAL SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33065-5081
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-656-8855
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | RICKI MOSKOW
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 954-656-8855
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 12804
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------