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General NPI Number Information
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NPI Number | 1790450104
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Entity Type | Organization
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Legal Business Name | MEDICOTEK INC
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Dates
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Enumeration Date | 08/09/2021
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Last Update Date | 10/27/2021
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Provider Practice Location Address
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Address Line | 6859 S EASTERN AVE STE 103
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City | LAS VEGAS
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State | NV
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Zip | 89119-0003
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Country | US
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Telephone | 702-778-4838
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Fax |
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Provider Business Mailing Address
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Address Line | 6859 S EASTERN AVE STE 103
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City | LAS VEGAS
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State | NV
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Zip | 89119-0003
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | MARIVIC LUNA BANAL
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Credential |
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Telephone | 702-778-4838
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RC0000X
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Taxonomy Name | Cardiovascular Disease Physician
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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 | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QR0200X
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Taxonomy Name | Radiology Clinic/Center
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License Number |
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License Number State |
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Taxonomy #4
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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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