Provider Demographics
NPI:1598703506
Name:GUADALUPE MEDICAL CENTER/OKAMOTO MD PC
Entity Type:Organization
Organization Name:GUADALUPE MEDICAL CENTER/OKAMOTO MD PC
Other - Org Name:GUADALUPE MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:ALDANA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-633-5410
Mailing Address - Street 1:1219 E CHARLESTON BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89104-1708
Mailing Address - Country:US
Mailing Address - Phone:702-633-5410
Mailing Address - Fax:702-320-1639
Practice Address - Street 1:1219 E CHARLESTON BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89104-1708
Practice Address - Country:US
Practice Address - Phone:702-633-5410
Practice Address - Fax:702-320-1639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100500942Medicaid
NV31211Medicare PIN
NV100500942Medicaid