Basic Information
| Provider Information | |||||||||
| NPI: | 1295712693 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FREMONT PRIMARY CARE - ENDOCRINOLOGY | ||||||||
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| OtherOrganizationName: | JOSLIN DIABETES CENTER AFFILIATE AT FREMONT MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1737 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891251737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7026716800 | ||||||||
| FaxNumber: | 7026716855 | ||||||||
| Practice Location | |||||||||
| Address1: | 4880 WYNN RD | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891035406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023623422 | ||||||||
| FaxNumber: | 7029398827 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | GRIFFIN | ||||||||
| AuthorizedOfficialFirstName: | JON | ||||||||
| AuthorizedOfficialMiddleName: | GREG | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7026716800 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133VN1006X | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered | Nutrition, Metabolic | 133V00000X | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered | 207RE0101X | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 363L00000X | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.