Provider Demographics
NPI:1508870445
Name:FAMILY TREE MEDICAL CENTER LLC
Entity Type:Organization
Organization Name:FAMILY TREE MEDICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TONY
Authorized Official - Middle Name:
Authorized Official - Last Name:GUMINA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-947-1000
Mailing Address - Street 1:PO BOX 231930
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89105-1930
Mailing Address - Country:US
Mailing Address - Phone:702-947-1000
Mailing Address - Fax:702-947-1001
Practice Address - Street 1:3510 E TROPICANA AVE
Practice Address - Street 2:STE # K
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-7341
Practice Address - Country:US
Practice Address - Phone:702-947-1000
Practice Address - Fax:702-947-1001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV9897207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002018528Medicaid
NV002018528Medicaid
NVV38433Medicare ID - Type Unspecified