1295079978 NPI number — ACCELLENCE LAS VEGAS

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 1295079978 NPI number — ACCELLENCE LAS VEGAS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ACCELLENCE LAS VEGAS
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:
1295079978
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/19/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
35 N EDISON WAY STE 37
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RENO
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89502-2352
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
775-787-8880
Provider Business Mailing Address Fax Number:
775-352-9333

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4815 W RUSSELL RD
Provider Second Line Business Practice Location Address:
STE 4D
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89118-6241
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-740-4138
Provider Business Practice Location Address Fax Number:
702-740-4153
Provider Enumeration Date:
11/19/2012

Additional Information

Authorized Official

Authorized Official Last Name:
HOWITT
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
R
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
775-787-8880

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  1000087786 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332BX2000X , with the licence number: 1000087786 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 003316057 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".




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