Provider Demographics
NPI:1881077451
Name:DESERT SHORES LLC
Entity type:Organization
Organization Name:DESERT SHORES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TED
Authorized Official - Middle Name:A
Authorized Official - Last Name:COHEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:702-339-8777
Mailing Address - Street 1:2235 N RAMPART BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-7640
Mailing Address - Country:US
Mailing Address - Phone:702-387-8777
Mailing Address - Fax:
Practice Address - Street 1:2235 N RAMPART BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-7640
Practice Address - Country:US
Practice Address - Phone:702-387-8777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-01
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVDPM9301213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV08442697Medicaid