1912103706 NPI number — BOWER TAKE CARE HEALTH NEVADA, PC

Table of content: (NPI 1912103706)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912103706 NPI number — BOWER TAKE CARE HEALTH NEVADA, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BOWER TAKE CARE HEALTH NEVADA, PC
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:
1912103706
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/22/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1901 E VOORHEES ST
Provider Second Line Business Mailing Address:
MS 640
Provider Business Mailing Address City Name:
DANVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61834-4509
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
855-925-4733
Provider Business Mailing Address Fax Number:
217-709-2345

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4905 W TROPICANA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
855-925-4733
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BOWER
Authorized Official First Name:
ANGELA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
855-925-4733

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 191210370 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".




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