1821216474 NPI number — ADVANCED SIERRA EYECARE, INC.

Table of content: (NPI 1821216474)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821216474 NPI number — ADVANCED SIERRA EYECARE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED SIERRA EYECARE, INC.
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:
DR. BENJAMIN C. SELJESTAD
Provider Other Organization Name Type Code:
5
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:
1821216474
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/04/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3450 CONTE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARSON CITY
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89701-4896
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
775-884-2020
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3033 N CARSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARSON CITY
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89706-0153
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
775-884-2020
Provider Business Practice Location Address Fax Number:
775-234-5434
Provider Enumeration Date:
04/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SELJESTAD
Authorized Official First Name:
BENJAMIN
Authorized Official Middle Name:
CLARK
Authorized Official Title or Position:
OD
Authorized Official Telephone Number:
775-884-2020

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  490 , 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: 13805 . This is a "SPECTERA" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
  • Identifier: 7944377 . This is a "AETNA" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".




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