Provider Demographics
NPI:1558547869
Name:S ROBERT LEAVER
Entity Type:Organization
Organization Name:S ROBERT LEAVER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:S
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:LEAVER
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:702-274-4566
Mailing Address - Street 1:4610 MEADOWS LN
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89107-2965
Mailing Address - Country:US
Mailing Address - Phone:702-274-4566
Mailing Address - Fax:702-878-1397
Practice Address - Street 1:4610 MEADOWS LN
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89107-2965
Practice Address - Country:US
Practice Address - Phone:702-274-4566
Practice Address - Fax:702-878-1397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-16
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVS3-17261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental