Provider Demographics
NPI:1215963756
Name:PRIMARY HEALTH LINE DIAGNOSTIC CENTER, INC
Entity type:Organization
Organization Name:PRIMARY HEALTH LINE DIAGNOSTIC CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:VALERI
Authorized Official - Middle Name:
Authorized Official - Last Name:KARAKHANOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-434-6486
Mailing Address - Street 1:2550 E DESERT INN RD
Mailing Address - Street 2:#329
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-3611
Mailing Address - Country:US
Mailing Address - Phone:702-434-6486
Mailing Address - Fax:702-436-0060
Practice Address - Street 1:3365 E FLAMINGO RD
Practice Address - Street 2:#3
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-7440
Practice Address - Country:US
Practice Address - Phone:702-434-6486
Practice Address - Fax:702-436-0060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100350Medicare ID - Type UnspecifiedNORIDIAN