Basic Information
| Provider Information | |||||||||
| NPI: | 1063526960 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HEART CENTER OF NEVADA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 SHADOW LN. | ||||||||
| Address2: | SUITE 240 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891064158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023840022 | ||||||||
| FaxNumber: | 7023840529 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 SHADOW LN. | ||||||||
| Address2: | SUITE 240 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891064158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023840022 | ||||||||
| FaxNumber: | 7023840529 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2006 | ||||||||
| LastUpdateDate: | 03/23/2011 | ||||||||
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| AuthorizedOfficialLastName: | WATTOO | ||||||||
| AuthorizedOfficialFirstName: | DOST | ||||||||
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| AuthorizedOfficialTitleorPosition: | SECRETARY/TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 7023840022 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | NV | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 100506158 | 05 | NV | MEDICAID |