Basic Information
| Provider Information | |||||||||
| NPI: | 1578077103 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SNNAC LLC | ||||||||
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| OtherOrganizationName: | AZURA SURGERY CENTER NORTHERN NEVADA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 40 VALLEY STREAM PKWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | MALVERN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193551407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106448900 | ||||||||
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| Practice Location | |||||||||
| Address1: | 932 RYLAND ST | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895021605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7758534166 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2017 | ||||||||
| LastUpdateDate: | 04/27/2020 | ||||||||
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| AuthorizedOfficialLastName: | SULLIVAN | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 7752325387 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | 04/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 250001294 | 05 | NV | MEDICAID |