MEDICARE: GOLDWYN INTEGRATED MEDICAL GROUP INC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	2084B0040X	Behavioral Neurology & Neuropsychiatry Physician
2	363L00000X	Nurse Practitioner
3	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1326816836
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOLDWYN INTEGRATED MEDICAL GROUP INC

Provider Business Mailing Address
First Line	:	2785 E DESERT INN RD STE 150
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-3699
Country	:	US
Telephone Number	:	760-220-1991
Fax Number	:

Provider Business Practice Location Address
First Line	:	2785 E DESERT INN RD STE 150
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-3699
Country	:	US
Telephone Number	:	760-220-1991
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ISABELLE SABALONES
Credential	:
Telephone Number	:	760-220-1991

Provider Enumeration Date	:	12/13/2023
Last Update Date	:	12/13/2023

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