Provider Demographics
NPI:1467978692
Name:SOUTHWEST PHYSICIAN MEDICAL DIAGNOSTIC CENTER
Entity Type:Organization
Organization Name:SOUTHWEST PHYSICIAN MEDICAL DIAGNOSTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AGENT
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:
Authorized Official - Last Name:MINTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-256-3637
Mailing Address - Street 1:PO BOX 370127
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89137-0127
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7341 W CHARLESTON BLVD STE 170
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-1578
Practice Address - Country:US
Practice Address - Phone:702-302-1460
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-18
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV8323261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV=========OtherTIN