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General NPI Number Information
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NPI Number | 1790936458
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Entity Type | Organization
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Legal Business Name | VAN WAGNER IMMEDIATE CARE CENTER
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Dates
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Enumeration Date | 09/30/2008
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Last Update Date | 10/01/2008
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Provider Practice Location Address
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Address Line | 2360 CORPORATE CIR SUITE 100
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City | HENDERSON
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State | NV
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Zip | 89074-7722
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Country | US
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Telephone | 702-990-0333
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Fax | 702-990-0336
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Provider Business Mailing Address
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Address Line | 2225 VILLAGE WALK DR SUITE 270
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City | HENDERSON
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State | NV
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Zip | 89052-5679
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Country | US
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Telephone | 702-990-0333
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Fax | 702-990-0336
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Authorized Official
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Title or Position | OWNER
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Name | DR. KELLY ELAN VAN WAGNER
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Credential | M.D.
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Telephone | 702-990-0333
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QU0200X
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Taxonomy Name | Urgent Care Clinic/Center
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License Number | 9533
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License Number State | NV
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