1124385976 NPI number — CHANWELL MEDICAL GROUP NEVADA INC

Table of content: (NPI 1124385976)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124385976 NPI number — CHANWELL MEDICAL GROUP NEVADA INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHANWELL MEDICAL GROUP NEVADA INC
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:
CHANWELL CLINIC
Provider Other Organization Name Type Code:
3
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:
1124385976
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/26/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3726 LAS VEGAS BLVD S UNIT 3501W
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89158-4399
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
408-828-2283
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2749 SUNRIDGE HEIGHTS PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HENDERSON
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89052-5044
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-568-0686
Provider Business Practice Location Address Fax Number:
702-568-0687
Provider Enumeration Date:
04/18/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CHAN
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
QUAN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
702-568-0686

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X , with the licence number:  042535 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM1300X , with the licence number: 42535 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QM1300X , with the licence number: A35593 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QS1200X , with the licence number: 042535 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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