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General NPI Number Information
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NPI Number | 1548201635
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Entity Type | Organization
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Legal Business Name | JACKSON HEALTH AND THEATER
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Dates
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Enumeration Date | 06/09/2006
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Last Update Date | 09/21/2007
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Provider Practice Location Address
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Address Line | 360 SOUTH LOLA LANE
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City | PAHRUMP
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State | NV
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Zip | 89048
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Country | US
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Telephone | 775-751-7833
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Fax |
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Provider Business Mailing Address
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Address Line | 11103 KILKERRAN CT
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City | LAS VEGAS
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State | NV
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Zip | 89141-4356
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Country | US
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Telephone | 702-326-2149
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | MICHAEL JACKSON
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Credential |
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Telephone | 702-326-2149
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | 10306
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License Number State | NV
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