Provider Demographics
NPI:1558429720
Name:LAS VEGAS CLINIC FOR CHILDREN & YOUTH
Entity Type:Organization
Organization Name:LAS VEGAS CLINIC FOR CHILDREN & YOUTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT MD
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:P
Authorized Official - Last Name:BUNCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-425-3566
Mailing Address - Street 1:501 7TH STREET
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701
Mailing Address - Country:US
Mailing Address - Phone:505-425-3566
Mailing Address - Fax:505-425-3568
Practice Address - Street 1:501 7TH STREET
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701
Practice Address - Country:US
Practice Address - Phone:505-425-3566
Practice Address - Fax:505-425-3568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM49395Medicaid