Basic Information
| Provider Information | |||||||||
| NPI: | 1043393309 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEVADA MEDICAL SYSTEMS, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 897 | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023991600 | ||||||||
| FaxNumber: | 7023995375 | ||||||||
| Practice Location | |||||||||
| Address1: | 2516 E LAKE MEAD BLVD | ||||||||
| Address2: | |||||||||
| City: | NORTH LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890306414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023991600 | ||||||||
| FaxNumber: | 7023995375 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2006 | ||||||||
| LastUpdateDate: | 06/06/2011 | ||||||||
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| AuthorizedOfficialLastName: | MASSMAN | ||||||||
| AuthorizedOfficialFirstName: | BRANT | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7023991600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2800X | 1938NTC-10 | NV | N | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic | 261QM2800X | NV | Y | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic |
ID Information
| ID | Type | State | Issuer | Description | 100502427 | 05 | NV | MEDICAID |