MEDICARE: AEVA CLINIC LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	261Q00000X	Clinic/Center
2	261QH0100X	Health Service Clinic/Center
3	261QM1300X	Multi-Specialty Clinic/Center
4	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1750886784
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AEVA CLINIC LLC

Provider Business Mailing Address
First Line	:	6280 S VALLEY VIEW BLVD STE 734
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89118-6833
Country	:	US
Telephone Number	:	702-558-2382
Fax Number	:

Provider Business Practice Location Address
First Line	:	4641 BLUE DIAMOND RD STE 120A
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89139-7610
Country	:	US
Telephone Number	:	702-558-2382
Fax Number	:	702-558-5407

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BARBARA DEINET
Credential	:
Telephone Number	:	702-219-6173

Provider Enumeration Date	:	03/30/2018
Last Update Date	:	09/18/2018

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Directions to “AEVA CLINIC LLC ” Practice Location

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