NPIMap

Organization Active NPI

Safe Harbor Medical, Inc.

  • Federally Qualified Health Center (FQHC)
  • Las Vegas, NV
National Provider Identifier
1083327456
Registry record updated Mar 4, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
SAFE HARBOR MEDICAL, INC.
Doing business as
Safe Harbor Medical
Practice address
2901 N Tenaya Way Ste 100
Las Vegas, NV 89128-1404
Phone
(702) 870-8852
Fax
(702) 870-8914
NPI assigned
Jan 2, 2023
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 4, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Tina A Alicea
Title
Ceo
Phone
(702) 870-8852

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

2901 N Tenaya Way Ste 100
Las Vegas, NV 89128-1404

Mailing address

2901 N Tenaya Way Ste 100
Las Vegas, NV 89128-1404
Phone (702) 870-8852

Other names 1

  • Safe Harbor Medical Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NV

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20240926000831 NV Part A Provider - Federally Qualified Health Center (FQHC) 6204903792 Practice locations: Las Vegas, NV

Federally qualified health center certification: CCN 291012

Legal name
SAFE HARBOR MEDICAL, INC.
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Aug 16, 2024
Last certification
Aug 16, 2024
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
May 17, 2024 in NV
Enrollment address
2901 N Tenaya Way
Ste 100
Las Vegas, NV 89128-1404

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
Safe Harbor Medical Inc6 organizations share this tax ID, including this one

Other organizations with this tax ID 5

Organizations that report the same tax identification number in the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 1

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Tina Alicea Individual 5% Or Greater Direct Ownership InterestCeo Mar 1, 2021 100%
Corporate OfficerCeo Mar 1, 2021 100%
W-2 Managing EmployeeCeo Mar 1, 2021 100%
Operational/Managerial ControlCeo Mar 1, 2021 100%

Practitioners & affiliated clinicians

Practitioners 9

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1672617600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1709510400000",
    "number": "1083327456",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2901 N TENAYA WAY STE 100",
            "city": "LAS VEGAS",
            "state": "NV",
            "postal_code": "891281404",
            "telephone_number": "702-870-8852",
            "fax_number": "702-870-8914"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2901 N TENAYA WAY STE 100",
            "city": "LAS VEGAS",
            "state": "NV",
            "postal_code": "891281404",
            "telephone_number": "702-870-8852",
            "fax_number": "702-870-8914"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SAFE HARBOR MEDICAL, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2023-01-02",
        "last_updated": "2024-03-04",
        "certification_date": "2024-03-04",
        "status": "A",
        "authorized_official_last_name": "ALICEA",
        "authorized_official_first_name": "TINA",
        "authorized_official_middle_name": "A",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "702-870-8852"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Safe Harbor Medical",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Safe Harbor Medical",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Las Vegas, NV

Sources for this page

Verify at the official NPI Registry.