Provider Demographics
NPI:1376736934
Name:FORT APACHE MEDICAL CENTER
Entity Type:Organization
Organization Name:FORT APACHE MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ANUSH
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVTYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-736-0049
Mailing Address - Street 1:6061 S FORT APACHE RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-5540
Mailing Address - Country:US
Mailing Address - Phone:702-736-0049
Mailing Address - Fax:702-736-0095
Practice Address - Street 1:6061 S FORT APACHE RD
Practice Address - Street 2:SUITE 120
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148-5540
Practice Address - Country:US
Practice Address - Phone:702-736-0049
Practice Address - Fax:702-736-0095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-27
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV754266207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty