Provider Demographics
NPI:1417154188
Name:PORFERIA MONTESCLAROS MD LLC
Entity Type:Organization
Organization Name:PORFERIA MONTESCLAROS MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PORFERIA
Authorized Official - Middle Name:D
Authorized Official - Last Name:MONTESCLAROS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-253-1173
Mailing Address - Street 1:2920 N GREEN VALLEY PKWY
Mailing Address - Street 2:BLDG 3 SUITE 312
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89014-0406
Mailing Address - Country:US
Mailing Address - Phone:702-253-1173
Mailing Address - Fax:702-253-1468
Practice Address - Street 1:2920 N GREEN VALLEY PKWY
Practice Address - Street 2:BLDG 3 SUITE 312
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89014-0406
Practice Address - Country:US
Practice Address - Phone:702-253-1173
Practice Address - Fax:702-253-1468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV115752084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVVMD102310Medicare ID - Type Unspecified