Basic Information
| Provider Information | |||||||||
| NPI: | 1568892545 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VALLEY PEDIATRIC & SPECIALTY CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3100 W CHARLESTON BLVD | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891022023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023884428 | ||||||||
| FaxNumber: | 7023884312 | ||||||||
| Practice Location | |||||||||
| Address1: | 3100 W CHARLESTON BLVD | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891022023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023884428 | ||||||||
| FaxNumber: | 7023884312 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/12/2013 | ||||||||
| LastUpdateDate: | 11/13/2013 | ||||||||
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| AuthorizedOfficialLastName: | MELOCOTON | ||||||||
| AuthorizedOfficialFirstName: | TERESITA | ||||||||
| AuthorizedOfficialMiddleName: | LU | ||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER | ||||||||
| AuthorizedOfficialTelephone: | 7023884428 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 9127 | NV | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.