1619007176 NPI number — WILDCREEK FAMILY MEDICAL CENTER

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 1619007176 NPI number — WILDCREEK FAMILY MEDICAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WILDCREEK FAMILY MEDICAL CENTER
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:
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:
1619007176
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/06/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2125 GREEN VISTA DR
Provider Second Line Business Mailing Address:
SUITE 106
Provider Business Mailing Address City Name:
SPARKS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89431-8545
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
775-673-6681
Provider Business Mailing Address Fax Number:
775-673-6682

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2125 GREEN VISTA DR
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
SPARKS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89431-8545
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
775-673-6681
Provider Business Practice Location Address Fax Number:
775-673-6682
Provider Enumeration Date:
03/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BOYD
Authorized Official First Name:
PHILLIS
Authorized Official Middle Name:
MAXINE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
775-673-6681

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DB9089 . This is a "RRMEDICARE" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
  • Identifier: 002016380 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".




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