Provider Demographics
NPI:1699336180
Name:CANADA MSO LLC
Entity type:Organization
Organization Name:CANADA MSO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:HARMEL-CANADA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:563-940-3806
Mailing Address - Street 1:8879 W FLAMINGO RD STE 101
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89147-8732
Mailing Address - Country:US
Mailing Address - Phone:702-646-1150
Mailing Address - Fax:
Practice Address - Street 1:8879 W FLAMINGO RD STE 101
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89147-8732
Practice Address - Country:US
Practice Address - Phone:702-646-1150
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-25
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center