Provider Demographics
NPI:1336477355
Name:ESSENTIAL MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:ESSENTIAL MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:VICKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PENCE
Authorized Official - Suffix:
Authorized Official - Credentials:MS,PAC
Authorized Official - Phone:602-881-8888
Mailing Address - Street 1:1485 E FLAMINGO RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-5256
Mailing Address - Country:US
Mailing Address - Phone:702-734-8600
Mailing Address - Fax:
Practice Address - Street 1:1485 E FLAMINGO RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-5256
Practice Address - Country:US
Practice Address - Phone:702-734-8600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-02
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV7546NV174400000X
NV965363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100510737Medicaid
1083791313OtherNPI
NVI65290OtherUPIN
NV1336199363OtherNPI
1083791313OtherNPI
NV100510737Medicaid