Provider Demographics
NPI:1255511739
Name:IRENE M. BOURGAULT DO PC
Entity type:Organization
Organization Name:IRENE M. BOURGAULT DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:IRENE
Authorized Official - Middle Name:MARY
Authorized Official - Last Name:BOURGAULT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:702-648-6228
Mailing Address - Street 1:3150 N TENAYA WAY STE 660
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-0460
Mailing Address - Country:US
Mailing Address - Phone:702-648-6228
Mailing Address - Fax:702-648-9868
Practice Address - Street 1:3150 N TENAYA WAY STE 660
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0460
Practice Address - Country:US
Practice Address - Phone:702-648-6228
Practice Address - Fax:702-648-9868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-13
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV350207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV32710OtherMEDICARE
NVV32709OtherMEDICARE GROUP
NVV39744OtherMEDICARE
NVH65342Medicare UPIN
NVV32710OtherMEDICARE
NVC95655Medicare UPIN
NV1740364918Medicare PIN