Provider Demographics
NPI:1548579022
Name:ST CLARE MEDICAL SERVICES INC
Entity type:Organization
Organization Name:ST CLARE MEDICAL SERVICES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-808-4741
Mailing Address - Street 1:7582 LAS VEGAS BLVD S
Mailing Address - Street 2:SUITE 489
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89123-1009
Mailing Address - Country:US
Mailing Address - Phone:702-878-2801
Mailing Address - Fax:702-878-3050
Practice Address - Street 1:2525 W CHARLESTON BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-2127
Practice Address - Country:US
Practice Address - Phone:702-878-2801
Practice Address - Fax:702-878-3050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-30
Last Update Date:2010-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV9215302R00000X, 305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
No302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002018374Medicaid
NV002018374Medicaid