Provider Demographics
NPI:1619394251
Name:SAFE HARBOR MEDICAL, INC.
Entity Type:Organization
Organization Name:SAFE HARBOR MEDICAL, INC.
Other - Org Name:SAFE HARBOR MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:A
Authorized Official - Last Name:ALICEA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-870-8852
Mailing Address - Street 1:2901 N TENAYA WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-1404
Mailing Address - Country:US
Mailing Address - Phone:702-870-8852
Mailing Address - Fax:702-870-8914
Practice Address - Street 1:2901 N TENAYA WAY STE 100
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-1404
Practice Address - Country:US
Practice Address - Phone:702-870-8852
Practice Address - Fax:702-870-8914
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-20
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV380207Q00000X
261QC1500X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty