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General NPI Number Information
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NPI Number | 1720355621
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Entity Type | Organization
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Legal Business Name | MUJICA TRENCHE - VITALITY MD PC
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Dates
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Enumeration Date | 11/19/2011
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Last Update Date | 03/16/2012
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Provider Practice Location Address
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Address Line | 6380 W FLAMINGO RD STE A
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City | LAS VEGAS
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State | NV
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Zip | 89103-7129
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Country | US
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Telephone | 702-888-0052
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 521
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City | ANDOVER
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State | KS
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Zip | 67002-0521
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Country | US
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Telephone | 316-927-3884
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Fax |
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Authorized Official
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Title or Position | SOLE MEMBER
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Name | DR. SAMUEL A MUJICA TRENCHE
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Credential | MD
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Telephone | 702-888-0052
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number |
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License Number State |
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