Provider Demographics
NPI:1255761128
Name:FIDELIS HEALTH GROUP LLC
Entity type:Organization
Organization Name:FIDELIS HEALTH GROUP LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WAGNER
Authorized Official - Middle Name:A
Authorized Official - Last Name:LEMUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-815-0800
Mailing Address - Street 1:5275 ARVILLE ST STE 156
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89118-4937
Mailing Address - Country:US
Mailing Address - Phone:702-815-0800
Mailing Address - Fax:702-815-0801
Practice Address - Street 1:5275 ARVILLE ST STE 156
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89118-4937
Practice Address - Country:US
Practice Address - Phone:702-815-0800
Practice Address - Fax:702-815-0801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-13
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336S0011X
NVPH030423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1255761128Medicaid