MEDICARE: NOT APPLICABLE

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	261QM2500X	Medical Specialty Clinic/Center

General Provider Information

NPI Number	:	1275183766
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NOT APPLICABLE

Provider Business Mailing Address
First Line	:	1820 FEATHERBROOK AVE
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-5052
Country	:	US
Telephone Number	:	702-900-1489
Fax Number	:

Provider Business Practice Location Address
First Line	:	2008 HAMILTON LN
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89106-4033
Country	:	US
Telephone Number	:	702-900-1489
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	YVETTE JONES
Credential	:
Telephone Number	:	702-350-1060

Provider Enumeration Date	:	09/17/2019
Last Update Date	:	10/11/2020

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Directions to “NOT APPLICABLE ” Practice Location

Language	Start Address	Practice Location

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