1467603878 NPI number — COMMUNITY CARE HEALTH PLAN OF NEVADA, INC.

Table of content: (NPI 1467603878)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467603878 NPI number — COMMUNITY CARE HEALTH PLAN OF NEVADA, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMUNITY CARE HEALTH PLAN OF NEVADA, 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:
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:
1467603878
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/17/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9133 WEST RUSSELL ROAD
Provider Second Line Business Mailing Address:
BUILDING 9
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89148-8351
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-545-9842
Provider Business Mailing Address Fax Number:
702-360-0755

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9133 WEST RUSSELL ROAD
Provider Second Line Business Practice Location Address:
BUILDING 9
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89148-8351
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-545-9842
Provider Business Practice Location Address Fax Number:
702-360-0755
Provider Enumeration Date:
10/03/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BOGARD
Authorized Official First Name:
LISA
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT AND CEO
Authorized Official Telephone Number:
702-545-9842

Provider Taxonomy Codes

  • Taxonomy code: 302R00000X , with the licence number:  17690 , 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: 100515750 . This is a "MEDICAID - NORTH" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
  • Identifier: 100515749 . This is a "MEDICAID - SOUTH" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
  • Identifier: 17690 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".




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