Provider Demographics
NPI:1821290115
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:MS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:A
Authorized Official - Last Name:ALICEA
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
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:2007-05-31
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV113458207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVNPIOther1932741048
NV100517352Medicaid
NV250007806Medicaid
NVNPIOther1457320004