Provider Demographics
NPI:1134421712
Name:CANYON GATE MEDICAL GROUP
Entity type:Organization
Organization Name:CANYON GATE MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:VERONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:COLON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-656-8855
Mailing Address - Street 1:2929 N UNIVERSITY DR
Mailing Address - Street 2:SUITE# 110
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33065-5081
Mailing Address - Country:US
Mailing Address - Phone:775-751-0695
Mailing Address - Fax:
Practice Address - Street 1:330 S LOLA LN
Practice Address - Street 2:SUITE# 200
Practice Address - City:PAHRUMP
Practice Address - State:NV
Practice Address - Zip Code:89048-0884
Practice Address - Country:US
Practice Address - Phone:954-656-8855
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-02
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV936207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty