Provider Demographics
NPI:1538778634
Name:CHOICE FAMILY MEDICAL CLINIC LLC
Entity type:Organization
Organization Name:CHOICE FAMILY MEDICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LETANIYA
Authorized Official - Middle Name:
Authorized Official - Last Name:WARREN TATUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-680-0600
Mailing Address - Street 1:400 N STEPHANIE ST STE 260
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89014-6800
Mailing Address - Country:US
Mailing Address - Phone:702-629-5555
Mailing Address - Fax:
Practice Address - Street 1:4185 VEGAS VALLEY DR STE C
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-2522
Practice Address - Country:US
Practice Address - Phone:702-463-9066
Practice Address - Fax:702-463-9067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-24
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2500010169Medicaid
NVNV20201837431OtherSTATE OF NEVADA