Basic Information
| Provider Information | |||||||||
| NPI: | 1902304769 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | C M MEDICAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 861 CORONADO CENTER DR STE 211 | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890523992 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024078241 | ||||||||
| FaxNumber: | 7024921728 | ||||||||
| Practice Location | |||||||||
| Address1: | 861 CORONADO CENTER DR STE 211 | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890523992 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024078241 | ||||||||
| FaxNumber: | 7024921728 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2018 | ||||||||
| LastUpdateDate: | 02/06/2018 | ||||||||
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| AuthorizedOfficialLastName: | BEAUCHAMP | ||||||||
| AuthorizedOfficialFirstName: | ALYONA | ||||||||
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| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 7024078241 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 17156 | NV | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 1912976762 | 01 | NPI | OTHER |