Provider Demographics
NPI:1073721361
Name:COMMUNITY OUTREACH MEDICAL CENTER
Entity Type:Organization
Organization Name:COMMUNITY OUTREACH MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KEMA
Authorized Official - Middle Name:
Authorized Official - Last Name:OGDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-657-3873
Mailing Address - Street 1:1090 E DESERT INN RD STE 200
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89109-2803
Mailing Address - Country:US
Mailing Address - Phone:702-657-3873
Mailing Address - Fax:702-636-0787
Practice Address - Street 1:1090 E DESERT INN RD STE 200
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109-2803
Practice Address - Country:US
Practice Address - Phone:702-657-3873
Practice Address - Fax:702-636-0787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV8907261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002018167Medicaid