Provider Demographics
NPI:1770285587
Name:NIBIRU MEDICAL CENTER LLC
Entity type:Organization
Organization Name:NIBIRU MEDICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ARTURO ERNESTO
Authorized Official - Middle Name:
Authorized Official - Last Name:VARELA QUILES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-510-9587
Mailing Address - Street 1:2235 E FLAMINGO RD STE 205
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-5152
Mailing Address - Country:US
Mailing Address - Phone:702-510-9587
Mailing Address - Fax:702-920-7677
Practice Address - Street 1:2235 E FLAMINGO RD STE 205
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-5152
Practice Address - Country:US
Practice Address - Phone:702-637-7534
Practice Address - Fax:702-920-7677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-17
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV250024181Medicaid