1821216474 NPI number — ADVANCED SIERRA EYECARE, INC.

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 1821216474 NPI number — ADVANCED SIERRA EYECARE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED SIERRA EYECARE, 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:
1821216474
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/04/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3450 CONTE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARSON CITY
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89701-4896
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
775-884-2020
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3033 N CARSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARSON CITY
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89706-0153
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
775-884-2020
Provider Business Practice Location Address Fax Number:
775-234-5434
Provider Enumeration Date:
04/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SELJESTAD
Authorized Official First Name:
BENJAMIN
Authorized Official Middle Name:
CLARK
Authorized Official Title or Position:
OD
Authorized Official Telephone Number:
775-884-2020

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  490 , 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: 13805 . This is a "SPECTERA" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
  • Identifier: 7944377 . This is a "AETNA" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".




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