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1721 E Charleston Blvd Las Vegas NV 89104 | |
| (702) 515-9680 | |
| Not Available |
| Full Name | |
|---|---|
| Speciality | Clinic/Center |
| Location | 1721 E Charleston Blvd, Las Vegas, Nevada |
| Authorized Official Name and Position | Festus Ebonka (OWNER/PRESIDENT) |
| Authorized Official Contact | 7025159680 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
1721 E Charleston Blvd Las Vegas NV 89104-1902 Ph: (702) 515-9680 | 1721 E Charleston Blvd Las Vegas NV 89104 Ph: (702) 515-9680 |
| NPI Number | 1457742975 |
|---|---|
| Provider Enumeration Date | 02/06/2015 |
| Last Update Date | 09/05/2018 |
| Medicare PECOS PAC ID | 3678893781 |
|---|---|
| Medicare Enrollment ID | O20150513000791 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1457742975 | NPI | - | NPPES |
| Provider Name | Festus O Ebonka |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1932241007 PECOS PAC ID: 3971609512 Enrollment ID: I20150513000946 |
| Provider Name | Priscilla Vernice Otoo-adjorlolo |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1780887463 PECOS PAC ID: 1759568470 Enrollment ID: I20190927001338 |
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