Provider Demographics
NPI:1790936458
Name:VAN WAGNER IMMEDIATE CARE CENTER
Entity Type:Organization
Organization Name:VAN WAGNER IMMEDIATE CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:ELAN
Authorized Official - Last Name:VAN WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-990-0333
Mailing Address - Street 1:2225 VILLAGE WALK DR
Mailing Address - Street 2:SUITE 270
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-5679
Mailing Address - Country:US
Mailing Address - Phone:702-990-0333
Mailing Address - Fax:702-990-0336
Practice Address - Street 1:2360 CORPORATE CIR
Practice Address - Street 2:SUITE 100
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89074-7722
Practice Address - Country:US
Practice Address - Phone:702-990-0333
Practice Address - Fax:702-990-0336
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VAN WAGNER HEALTHCARE MANAGEMENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-09-30
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV9533261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care