1225101330 NPI number — INNOTIV GERMIN

Table of content: (NPI 1225101330)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225101330 NPI number — INNOTIV GERMIN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INNOTIV GERMIN
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CLINICAL NEUROLOGY SPECIALISTS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225101330
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/20/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 530786
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HENDERSON
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89053-0786
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-804-1212
Provider Business Mailing Address Fax Number:
702-804-1222

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1691 W HORIZON RIDGE PKWY
Provider Second Line Business Practice Location Address:
#100
Provider Business Practice Location Address City Name:
HENDERSON
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89012-3494
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-804-1212
Provider Business Practice Location Address Fax Number:
702-804-1222
Provider Enumeration Date:
11/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GERMIN
Authorized Official First Name:
LEO
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
702-804-1212

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  7866 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 002019758 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".




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