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General NPI Number Information
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NPI Number | 1639720105
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Entity Type | Organization
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Legal Business Name | INTERCITY MEDICAL AND CONSULTING RESOURCES LLC
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Dates
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Enumeration Date | 09/25/2019
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Last Update Date | 09/25/2019
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Provider Practice Location Address
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Address Line | 4100 W FLAMINGO RD
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City | LAS VEGAS
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State | NV
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Zip | 89103-3924
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Country | US
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Telephone | 888-354-2758
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Fax |
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Provider Business Mailing Address
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Address Line | 848 N RAINBOW BLVD # 1508
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City | LAS VEGAS
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State | NV
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Zip | 89107-1103
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Country | US
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Telephone | 888-354-2758
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | ELIAS LU
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Credential |
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Telephone | 888-354-2758
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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