1588049316 NPI number — SPENCER EARNEST

Table of content: SPENCER EARNEST (NPI 1588049316)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588049316 NPI number — SPENCER EARNEST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EARNEST
Provider First Name:
SPENCER
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

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:
1588049316
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/02/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
66 N PECOS RD
Provider Second Line Business Mailing Address:
STE C
Provider Business Mailing Address City Name:
HENDERSON
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89074-7338
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-564-6712
Provider Business Mailing Address Fax Number:
702-564-4838

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
66 N PECOS RD
Provider Second Line Business Practice Location Address:
STE C
Provider Business Practice Location Address City Name:
HENDERSON
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89074-7338
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-564-6712
Provider Business Practice Location Address Fax Number:
702-564-4838
Provider Enumeration Date:
07/22/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  3166 , 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)