Basic Information
Provider Information | |||||||||
NPI: | 1497153530 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PRIME HEALTHCARE SERVICES NORTH VISTA LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1409 E LAKE MEAD BLVD | ||||||||
Address2: |   | ||||||||
City: | NORTH LAS VEGAS | ||||||||
State: | NV | ||||||||
PostalCode: | 890307120 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7026497711 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1409 E LAKE MEAD BLVD | ||||||||
Address2: |   | ||||||||
City: | NORTH LAS VEGAS | ||||||||
State: | NV | ||||||||
PostalCode: | 890307120 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7026497711 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/05/2014 | ||||||||
LastUpdateDate: | 12/05/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | REDDY | ||||||||
AuthorizedOfficialFirstName: | PREM | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHAIRMAN/PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 9092354400 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | PRIME HEALTHCARE SERVICES NORTH VISTA LLC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 649HOS-34 | NV | Y |   | Hospital Units | Psychiatric Unit |   |
ID Information
ID | Type | State | Issuer | Description | 100502300 | 05 | NV |   | MEDICAID | 100502301 | 05 | NV |   | MEDICAID | 100502299 | 05 | NV |   | MEDICAID |