Basic Information
| Provider Information | |||||||||
| NPI: | 1245430446 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ISD LAS VEGAS LLC | ||||||||
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| OtherOrganizationName: | GREEN VALLEY DIALYSIS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5200 VIRGINIA WAY | ||||||||
| Address2: | LICENSURE & CERTIFICATION | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370277569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153416814 | ||||||||
| FaxNumber: | 8002938405 | ||||||||
| Practice Location | |||||||||
| Address1: | 1489 W WARM SPRINGS RD | ||||||||
| Address2: | STE 122 | ||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890147637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024508877 | ||||||||
| FaxNumber: | 7024508887 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2007 | ||||||||
| LastUpdateDate: | 06/26/2020 | ||||||||
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| AuthorizedOfficialLastName: | WINSTEL | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF ACCOUNTING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2537334501 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | 1245430446 | 05 | NV | MEDICAID |