=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508246752
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GOLDSMITH HEALTHCARE, LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2015
-----------------------------------------------------
Last Update Date | 06/03/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5375 S FORT APACHE RD 102-103
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89148-7623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-646-9444
-----------------------------------------------------
Fax | 702-646-9022
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5375 S FORT APACHE RD 102-103
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89148-7623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-646-9444
-----------------------------------------------------
Fax | 702-646-9022
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DIRECTOR
-----------------------------------------------------
Name | DR. IVAN LEE GOLDSMITH
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 702-646-9444
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 6116
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------