MEDICARE: SALTY LIGHT LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	208D00000X	General Practice Physician
2	207R00000X	Internal Medicine Physician
3	207X00000X	Orthopaedic Surgery Physician
4	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1912898701
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SALTY LIGHT LLC

Provider Business Mailing Address
First Line	:	1477 E LAKE MEAD PKWY STE 130
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89015-4647
Country	:	US
Telephone Number	:	725-726-2364
Fax Number	:

Provider Business Practice Location Address
First Line	:	1477 E LAKE MEAD PKWY STE 130
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89015-4647
Country	:	US
Telephone Number	:	725-726-2364
Fax Number	:

Authorized Official
Title or Position	:	OFFICE ADMINISTRATOR
Name	:	HEATHER CLAWSON
Credential	:
Telephone Number	:	725-726-2364

Provider Enumeration Date	:	07/10/2025
Last Update Date	:	02/04/2026

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Directions to “SALTY LIGHT LLC ” Practice Location

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