Provider Demographics
NPI:1295712693
Name:FREMONT PRIMARY CARE - ENDOCRINOLOGY
Entity type:Organization
Organization Name:FREMONT PRIMARY CARE - ENDOCRINOLOGY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:GREG
Authorized Official - Last Name:GRIFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-671-6800
Mailing Address - Street 1:PO BOX 1737
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89125-1737
Mailing Address - Country:US
Mailing Address - Phone:702-671-6800
Mailing Address - Fax:702-671-6855
Practice Address - Street 1:4880 WYNN RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-5406
Practice Address - Country:US
Practice Address - Phone:702-362-3422
Practice Address - Fax:702-939-8827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, MetabolicGroup - Single Specialty
Not Answered133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Not Answered207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Not Answered363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
37629Medicare ID - Type Unspecified