1679706790 NPI number — DIGESTIVE DISEASE CENTER-GREEN VALLEY

Table of content: (NPI 1679706790)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679706790 NPI number — DIGESTIVE DISEASE CENTER-GREEN VALLEY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIGESTIVE DISEASE CENTER-GREEN VALLEY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679706790
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/05/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1647 WINDMILL LANE
Provider Second Line Business Mailing Address:
SUITE 110
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89123
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-628-5830
Provider Business Mailing Address Fax Number:
702-270-8984

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1647 WINDMILL LANE
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89123
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-628-5830
Provider Business Practice Location Address Fax Number:
702-270-8984
Provider Enumeration Date:
08/25/2009

Additional Information

Authorized Official

Authorized Official Last Name:
HAIKAL
Authorized Official First Name:
OSAMA
Authorized Official Middle Name:
OMAR
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
702-734-0505

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  2000772.650 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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