Provider Demographics
NPI:1336665348
Name:KIDDIES PAL LLC
Entity Type:Organization
Organization Name:KIDDIES PAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:TAL
Authorized Official - Middle Name:
Authorized Official - Last Name:MINUSKIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-823-1333
Mailing Address - Street 1:851 S RAMPART BLVD STE 130
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89145-4884
Mailing Address - Country:US
Mailing Address - Phone:702-823-1333
Mailing Address - Fax:702-823-1190
Practice Address - Street 1:851 S RAMPART BLVD STE 130
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89145-4884
Practice Address - Country:US
Practice Address - Phone:702-823-1333
Practice Address - Fax:702-823-1190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100537177Medicaid