Provider Demographics
NPI:1407513104
Name:FLORES, CHARLES BENEDICT
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:BENEDICT
Last Name:FLORES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3792 LODINA CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89141-3510
Mailing Address - Country:US
Mailing Address - Phone:702-580-4601
Mailing Address - Fax:
Practice Address - Street 1:2633 HICKEY AVE
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030-7398
Practice Address - Country:US
Practice Address - Phone:702-324-4056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-17
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1605212865Medicaid