1184111890 NPI number — PAIN CENTER OF HENDERSON LLC

Table of content: (NPI 1184111890)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184111890 NPI number — PAIN CENTER OF HENDERSON LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAIN CENTER OF HENDERSON 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:
PAIN CENTER OF HENDERSON
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:
1184111890
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/06/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
98 E. LAKE MEAD PKWY.
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
HENDERSON
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89015
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-476-5552
Provider Business Mailing Address Fax Number:
702-476-5181

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
98 E. LAKE MEAD PKWY. SUITE 202
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HENDERSON
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89015
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-476-5552
Provider Business Practice Location Address Fax Number:
702-476-5181
Provider Enumeration Date:
04/18/2018

Additional Information

Authorized Official

Authorized Official Last Name:
OLENCHAK
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
PROVIDER, OWNER
Authorized Official Telephone Number:
702-476-5552

Provider Taxonomy Codes

  • Taxonomy code: 208VP0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 12432512 . This is a "CAQH" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com