Basic Information
| Provider Information | |||||||||
| NPI: | 1295701480 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEVADA HISTOLOGY, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1350 STARDUST ST | ||||||||
| Address2: | SUITE D | ||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895034264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7757472211 | ||||||||
| FaxNumber: | 7757463411 | ||||||||
| Practice Location | |||||||||
| Address1: | 1350 STARDUST ST | ||||||||
| Address2: | SUITE D | ||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895034264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7757472211 | ||||||||
| FaxNumber: | 7757463411 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BLUM | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | GENERAL MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7757463400 | ||||||||
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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 | 291U00000X | 1512LIC-5 | NV | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | G44897 | 01 | NV | MANSON | OTHER | XPY068120 | 01 | NV | MEDICAL | OTHER |