1881577815 NPI number — ARVAMA MEDICAL CENTER LLC

Table of content: (NPI 1881577815)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881577815 NPI number — ARVAMA MEDICAL CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ARVAMA MEDICAL CENTER 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:
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:
1881577815
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/01/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3543 WINGROVE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89121-3550
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-504-6590
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4660 S EASTERN AVE STE 205
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89119-6139
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-504-6590
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/28/2025

Additional Information

Authorized Official

Authorized Official Last Name:
MARTIN MANSO
Authorized Official First Name:
ALEXEY
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICER MANAGER
Authorized Official Telephone Number:
702-504-6590

Provider Taxonomy Codes

  • Taxonomy code: 2084B0040X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1705319639 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".




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