MEDICARE: FAITH MEDICAL CLINIC, 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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1700485083
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAITH MEDICAL CLINIC, LLC.

Provider Business Mailing Address
First Line	:	3510 E TROPICANA AVE STE K
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-7341
Country	:	US
Telephone Number	:	702-466-0069
Fax Number	:	702-433-1815

Provider Business Practice Location Address
First Line	:	3510 E TROPICANA AVE STE K
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-7341
Country	:	US
Telephone Number	:	702-466-0069
Fax Number	:	702-433-1815

Authorized Official
Title or Position	:	MANAGER
Name	:	MR. DANIEL MONCADA
Credential	:
Telephone Number	:	702-902-3039

Provider Enumeration Date	:	10/19/2020
Last Update Date	:	10/19/2020

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