Basic Information
| Provider Information | |||||||||
| NPI: | 1831234558 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BOULDER CITY HOSPITAL INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | BOULDER CITY HOSPITAL SKILLED NURSING FACILITY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 901 ADAMS BOULEVARD | ||||||||
| Address2: | |||||||||
| City: | BOULDER CITY | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890052213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022934111 | ||||||||
| FaxNumber: | 7022945732 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 ADAMS BOULEVARD | ||||||||
| Address2: | |||||||||
| City: | BOULDER CITY | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890052213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022934111 | ||||||||
| FaxNumber: | 7022945732 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2007 | ||||||||
| LastUpdateDate: | 11/21/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BELETE | ||||||||
| AuthorizedOfficialFirstName: | FREZEWED | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 7022934111 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BOULDER CITY HOSPITAL INC | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 633HOS11 | NV | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 001802839 | 05 | NV | MEDICAID |