Basic Information
| Provider Information | |||||||||
| NPI: | 1598751257 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHERN SIERRA DIALYSIS CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 E SECOND ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895021189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7759828155 | ||||||||
| FaxNumber: | 7759828104 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 E 2ND ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895021181 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7759828155 | ||||||||
| FaxNumber: | 7759828104 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2005 | ||||||||
| LastUpdateDate: | 12/28/2009 | ||||||||
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| AuthorizedOfficialLastName: | VAN WAGNER | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF DIALYSIS | ||||||||
| AuthorizedOfficialTelephone: | 7759824027 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | 34710ESR-3 | NV | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
No ID Information.