Basic Information
| Provider Information | |||||||||
| NPI: | 1912264524 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MILLENNIUM HOSPITALIST COMPANY OF BOULDER CITY | ||||||||
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| OtherOrganizationName: | MHC OF BOULDER CITY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3375 S RAINBOW BLVD | ||||||||
| Address2: | UNIT 80751 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891808801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024533799 | ||||||||
| FaxNumber: | 7024535741 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 ADAMS BLVD | ||||||||
| Address2: | |||||||||
| City: | BOULDER CITY | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890052213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024533799 | ||||||||
| FaxNumber: | 7024535741 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2012 | ||||||||
| LastUpdateDate: | 07/30/2015 | ||||||||
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| AuthorizedOfficialLastName: | LABRECQUE | ||||||||
| AuthorizedOfficialFirstName: | LORI | ||||||||
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| AuthorizedOfficialTitleorPosition: | ACCOUNTS MGR | ||||||||
| AuthorizedOfficialTelephone: | 7024533799 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 13058 | NV | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 53666-20 | 01 | WI | WI LIC | OTHER | 13058 | 01 | NV | NV LIC | OTHER |