1164487930 NPI number — SUNSHINE VALLEY HEALTH CARE-WESLEY J. ROBERTSON M.D. PROF. CORP.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164487930 NPI number — SUNSHINE VALLEY HEALTH CARE-WESLEY J. ROBERTSON M.D. PROF. CORP.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUNSHINE VALLEY HEALTH CARE-WESLEY J. ROBERTSON M.D. PROF. CORP.
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:
1164487930
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/12/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
653 N TOWN CENTER DR
Provider Second Line Business Mailing Address:
SUITE 106
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89144-0514
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-363-3000
Provider Business Mailing Address Fax Number:
702-363-3161

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
653 N TOWN CENTER DR
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89144-0514
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-363-3000
Provider Business Practice Location Address Fax Number:
702-363-3161
Provider Enumeration Date:
04/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ROBERTSON
Authorized Official First Name:
WESLEY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
702-363-3000

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  7487 , 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: 002019564 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100503771 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100502879 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 002018144 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".




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