Provider Demographics
NPI:1639352453
Name:CAPSULE ENDOSCOPY SERVICES INC.
Entity type:Organization
Organization Name:CAPSULE ENDOSCOPY SERVICES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROME
Authorized Official - Middle Name:
Authorized Official - Last Name:JUTABHA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-478-7941
Mailing Address - Street 1:100 UCLA MEDICAL PLAZA
Mailing Address - Street 2:SUITE 310
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-0001
Mailing Address - Country:US
Mailing Address - Phone:310-825-5381
Mailing Address - Fax:310-825-5390
Practice Address - Street 1:9499 W CHARLESTON BLVD
Practice Address - Street 2:SUITE 150
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-7147
Practice Address - Country:US
Practice Address - Phone:702-478-7941
Practice Address - Fax:702-478-7951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-14
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV11774261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW19041Medicare PIN