Provider Demographics
NPI:1972031417
Name:CHUYS MEDICAL CLINIC
Entity Type:Organization
Organization Name:CHUYS MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JESUS
Authorized Official - Middle Name:
Authorized Official - Last Name:CORN-SOTELO
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:702-695-6576
Mailing Address - Street 1:4225 S EASTERN AVE STE 8
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-5485
Mailing Address - Country:US
Mailing Address - Phone:702-982-5786
Mailing Address - Fax:702-982-5871
Practice Address - Street 1:4225 S EASTERN AVE STE 8
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-5485
Practice Address - Country:US
Practice Address - Phone:702-982-5786
Practice Address - Fax:702-982-5871
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-29
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center