Provider Demographics
NPI:1104089614
Name:SIERRA VISTA MEDICAL ASSOCIATES LLC
Entity type:Organization
Organization Name:SIERRA VISTA MEDICAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:VACEK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:775-250-7636
Mailing Address - Street 1:1180 SELMI DR SUITE 201
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89512-4776
Mailing Address - Country:US
Mailing Address - Phone:775-250-7636
Mailing Address - Fax:
Practice Address - Street 1:1180 SELMI DR SUITE 201
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89512-4776
Practice Address - Country:US
Practice Address - Phone:775-250-7636
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-03
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1125207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100501342Medicaid
NV100501342Medicaid