Basic Information
| Provider Information | |||||||||
| NPI: | 1770686255 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHERN SIERRA DIALYSIS CENTER, LLC. | ||||||||
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| OtherOrganizationName: | NORTHERN SIERRA DIALYSIS CENTER AT SOUTH MEADOWS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 E 2ND ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895021189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7759824027 | ||||||||
| FaxNumber: | 7759828104 | ||||||||
| Practice Location | |||||||||
| Address1: | 10085 DOUBLE R BLVD | ||||||||
| Address2: | STE 160 | ||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 89511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7759824027 | ||||||||
| FaxNumber: | 7759828104 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2006 | ||||||||
| LastUpdateDate: | 09/30/2008 | ||||||||
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| AuthorizedOfficialLastName: | VAN WAGNER | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | KEITH | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7759824027 | ||||||||
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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 | 261QE0700X | 3410ESR-4 | NV | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
No ID Information.