Provider Demographics
NPI:1104802297
Name:SIERRA REGIONAL SPINE INSTITUTE
Entity type:Organization
Organization Name:SIERRA REGIONAL SPINE INSTITUTE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PENNY
Authorized Official - Middle Name:A
Authorized Official - Last Name:FORBES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-828-2873
Mailing Address - Street 1:6630 S MCCARRAN BLVD STE A4
Mailing Address - Street 2:SIERRA REGIONAL SPINE INSTITUTE
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89509-6158
Mailing Address - Country:US
Mailing Address - Phone:775-828-2873
Mailing Address - Fax:775-828-2889
Practice Address - Street 1:6630 S MCCARRAN BLVD STE A4
Practice Address - Street 2:SIERRA REGIONAL SPINE INSTITUTE
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-6158
Practice Address - Country:US
Practice Address - Phone:775-828-2873
Practice Address - Fax:775-828-2889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-20
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV207XS0117X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVVWQBHBMedicare PIN