Provider Demographics
NPI:1639791791
Name:SPRING MOUNTAIN MEDICAL CENTER PLLC
Entity Type:Organization
Organization Name:SPRING MOUNTAIN MEDICAL CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAFAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:OKAMOTO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-376-7853
Mailing Address - Street 1:4276 SPRING MOUNTAIN RD UNIT 211
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-8781
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4276 SPRING MOUNTAIN RD UNIT 211
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-8781
Practice Address - Country:US
Practice Address - Phone:702-802-8567
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-12
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1235281874Medicaid