MEDICARE: PORFERIA MONTESCLAROS MD LLC

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	2084P0800X	Psychiatry Physician	11575	NV

General Provider Information

NPI Number	:	1417154188
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PORFERIA MONTESCLAROS MD LLC

Provider Business Mailing Address
First Line	:	2920 N GREEN VALLEY PKWY
Second Line	:	BLDG 3 SUITE 312
City	:	HENDERSON
State	:	NV
Zip	:	89014-0406
Country	:	US
Telephone Number	:	702-253-1173
Fax Number	:	702-253-1468

Provider Business Practice Location Address
First Line	:	2920 N GREEN VALLEY PKWY
Second Line	:	BLDG 3 SUITE 312
City	:	HENDERSON
State	:	NV
Zip	:	89014-0406
Country	:	US
Telephone Number	:	702-253-1173
Fax Number	:	702-253-1468

Authorized Official
Title or Position	:	OWNER
Name	:	DR. PORFERIA D MONTESCLAROS
Credential	:	MD
Telephone Number	:	702-253-1173

Provider Enumeration Date	:	06/27/2007
Last Update Date	:	08/22/2020

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