MEDICARE: PRIMARY HEALTH LINE DIAGNOSTIC CENTER, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085U0001X	Diagnostic Ultrasound Physician

General Provider Information

NPI Number	:	1215963756
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIMARY HEALTH LINE DIAGNOSTIC CENTER, INC

Provider Business Mailing Address
First Line	:	2550 E DESERT INN RD
Second Line	:	#329
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-3611
Country	:	US
Telephone Number	:	702-434-6486
Fax Number	:	702-436-0060

Provider Business Practice Location Address
First Line	:	3365 E FLAMINGO RD
Second Line	:	#3
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-7440
Country	:	US
Telephone Number	:	702-434-6486
Fax Number	:	702-436-0060

Authorized Official
Title or Position	:	OWNER
Name	:	MR. VALERI KARAKHANOV
Credential	:
Telephone Number	:	702-434-6486

Provider Enumeration Date	:	06/25/2006
Last Update Date	:	08/22/2020

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