Basic Information
| Provider Information | |||||||||
| NPI: | 1831278720 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NEVADA HEALTH CENTERS, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AMARGOSA VALLEY MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3325 RESEARCH WAY | ||||||||
| Address2: | ATTN: PAT | ||||||||
| City: | CARSON CITY | ||||||||
| State: | NV | ||||||||
| PostalCode: | 897067913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7758886610 | ||||||||
| FaxNumber: | 7758884904 | ||||||||
| Practice Location | |||||||||
| Address1: | 1690 E AMARGOSA FARM RD | ||||||||
| Address2: | |||||||||
| City: | AMARGOSA VALLEY | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890209735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7753725432 | ||||||||
| FaxNumber: | 7753721303 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2006 | ||||||||
| LastUpdateDate: | 02/05/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | WALTER | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7758886610 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NEVADA HEALTH CENTERS, INC. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 291803 | NV | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | DQ468D | 01 | NV | MEDICARE ID-TYPE UNSPECIFIED | OTHER | 1831278720 | 05 | NV | MEDICAID |