1275588782 NPI number — MMC OF NEVADA LLC

Table of content: (NPI 1275588782)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275588782 NPI number — MMC OF NEVADA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MMC OF NEVADA LLC
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:
MESA VIEW REGIONAL HOSPITAL
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:
1275588782
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/11/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 847743
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75284-7743
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-346-8040
Provider Business Mailing Address Fax Number:
702-346-7031

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1299 BERTHA HOWE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MESQUITE
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89027-7500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-346-8040
Provider Business Practice Location Address Fax Number:
702-346-7031
Provider Enumeration Date:
05/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
COOPER
Authorized Official First Name:
RANDY
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
SVP FINANCE OP/AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
615-221-3840

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 282N00000X , with the licence number: 3818HOS-3 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 282NC0060X , with the licence number: 3818HOS-3 , 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: XHSP33686 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100505424 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
  • Identifier: XHSP43686 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100505425 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 884024 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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