Provider Demographics
NPI:1124385976
Name:CHANWELL MEDICAL GROUP NEVADA INC
Entity Type:Organization
Organization Name:CHANWELL MEDICAL GROUP NEVADA INC
Other - Org Name:CHANWELL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:QUAN
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-568-0686
Mailing Address - Street 1:3726 LAS VEGAS BLVD S UNIT 3501W
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89158-4399
Mailing Address - Country:US
Mailing Address - Phone:408-828-2283
Mailing Address - Fax:
Practice Address - Street 1:2749 SUNRIDGE HEIGHTS PKWY
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-5044
Practice Address - Country:US
Practice Address - Phone:702-568-0686
Practice Address - Fax:702-568-0687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-18
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA042535261QM1300X, 261QS1200X
CA42535261QM1300X
CAA35593261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAQ523ZMedicare PIN