Provider Demographics
NPI:1790465698
Name:THE VICE PRACTICE LLC
Entity Type:Organization
Organization Name:THE VICE PRACTICE LLC
Other - Org Name:THE VICE PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:SUSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRELES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-630-5740
Mailing Address - Street 1:9160 MOHAWK ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89139-7508
Mailing Address - Country:US
Mailing Address - Phone:702-931-1434
Mailing Address - Fax:
Practice Address - Street 1:2480 E TOMPKINS AVE STE 101
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-5466
Practice Address - Country:US
Practice Address - Phone:725-724-2005
Practice Address - Fax:877-418-8013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-24
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty