Basic Information
| Provider Information | |||||||||
| NPI: | 1134377153 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DIAGNOSTIC CENTER OF MEDICINE (ALLEN) LLP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DIAGNOSTIC CENTER OF MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3012 S DURANGO DR | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891179186 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023661655 | ||||||||
| FaxNumber: | 7023854955 | ||||||||
| Practice Location | |||||||||
| Address1: | 5380 S RAINBOW BLVD | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891181877 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022333444 | ||||||||
| FaxNumber: | 7022336998 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2008 | ||||||||
| LastUpdateDate: | 09/03/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ALLEN | ||||||||
| AuthorizedOfficialFirstName: | LAWRENCE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7023660640 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DIAGNOSTIC CENTER OF MEDICINE (ALLEN) LLP | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100501975 | 05 | NV | MEDICAID |