Basic Information
| Provider Information | |||||||||
| NPI: | 1841277209 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FREMONT WOMEN'S HEALTH, LLC | ||||||||
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| OtherOrganizationName: | FREMONT WOMENS HEALTH CARE | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 612 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891250612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7026716800 | ||||||||
| FaxNumber: | 7026716883 | ||||||||
| Practice Location | |||||||||
| Address1: | 3150 N TENAYA WAY | ||||||||
| Address2: | STE 635 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891280443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7028702939 | ||||||||
| FaxNumber: | 7028702826 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2005 | ||||||||
| LastUpdateDate: | 01/15/2009 | ||||||||
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| AuthorizedOfficialLastName: | GRIFFIN | ||||||||
| AuthorizedOfficialFirstName: | JON | ||||||||
| AuthorizedOfficialMiddleName: | GREG | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7026716800 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2471S1302X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist | Sonography | 363A00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363LX0001X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Obstetrics & Gynecology | 207V00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 100507673 | 05 | NV | MEDICAID |