Basic Information
| Provider Information | |||||||||
| NPI: | 1427507912 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARLOS | ||||||||
| FirstName: | LOREN | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5820 MICHAEL DEAN ST | ||||||||
| Address2: | |||||||||
| City: | NORTH LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890814422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9255495407 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3909 S MARYLAND PKWY | ||||||||
| Address2: | 311 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891197500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8885318385 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2016 | ||||||||
| LastUpdateDate: | 09/26/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | NV | Y |
No ID Information.