Provider Demographics
NPI:1962050716
Name:HEART MEDICAL GROUP
Entity type:Organization
Organization Name:HEART MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AGENT
Authorized Official - Prefix:
Authorized Official - First Name:VIVIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:OWYONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-235-5778
Mailing Address - Street 1:1210 S VALLEY VIEW BLVD
Mailing Address - Street 2:UNIT 102
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102
Mailing Address - Country:US
Mailing Address - Phone:702-235-5778
Mailing Address - Fax:
Practice Address - Street 1:1210 S VALLEY VIEW BLVD
Practice Address - Street 2:UNIT 102
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102
Practice Address - Country:US
Practice Address - Phone:702-235-5778
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-26
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent MedicineGroup - Single Specialty