Provider Demographics
NPI:1023576840
Name:HCPN AT CITY IMPACT WELLNESS CLINIC LLC
Entity Type:Organization
Organization Name:HCPN AT CITY IMPACT WELLNESS CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:
Authorized Official - Last Name:VIRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-871-9917
Mailing Address - Street 1:4850 W FLAMINGO RD STE 25
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-3707
Mailing Address - Country:US
Mailing Address - Phone:702-871-9917
Mailing Address - Fax:
Practice Address - Street 1:968 E SAHARA AVE STE C
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89104-3022
Practice Address - Country:US
Practice Address - Phone:702-871-9917
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-11
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty