1790873966 NPI number — FLAMINGO PECOS SURGERY LLC

Table of content: (NPI 1790873966)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790873966 NPI number — FLAMINGO PECOS SURGERY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FLAMINGO PECOS SURGERY 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:
Provider Other Organization Name Type Code:
6
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:
1790873966
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/11/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2110 E FLAMINGO RD
Provider Second Line Business Mailing Address:
SUITE 109
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89119-5190
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-868-2796
Provider Business Mailing Address Fax Number:
702-650-5099

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4275 BURNHAM AVE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89119-5488
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-933-8088
Provider Business Practice Location Address Fax Number:
702-933-5040
Provider Enumeration Date:
10/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BARNES
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
W.
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
702-868-2796

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100500440 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".




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