Provider Demographics
NPI:1366606139
Name:ICARELASVEGAS
Entity type:Organization
Organization Name:ICARELASVEGAS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE-MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:GABRIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:702-631-4144
Mailing Address - Street 1:6134 W LAKE MEAD BLVD
Mailing Address - Street 2:E-8
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89108-2659
Mailing Address - Country:US
Mailing Address - Phone:702-631-4144
Mailing Address - Fax:702-631-9094
Practice Address - Street 1:6134 W LAKE MEAD BLVD
Practice Address - Street 2:E-8
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89108-2659
Practice Address - Country:US
Practice Address - Phone:702-631-4144
Practice Address - Fax:702-631-9094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-11
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV557152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVBH615AOtherMEDICARE PTAN