Provider Demographics
NPI:1699738872
Name:NORTHERN NEVADA AMBULATORY SURGICAL CENTER LLC
Entity type:Organization
Organization Name:NORTHERN NEVADA AMBULATORY SURGICAL CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:INGRAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-954-0600
Mailing Address - Street 1:5411 KIETZKE LANE
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89511
Mailing Address - Country:US
Mailing Address - Phone:775-954-0600
Mailing Address - Fax:775-954-0612
Practice Address - Street 1:5411 KIETZKE LANE
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89511
Practice Address - Country:US
Practice Address - Phone:775-954-0600
Practice Address - Fax:775-954-0612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-10
Last Update Date:2010-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2048ASC-12261QA1903X
NV2048ASC-19261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV004616009Medicaid
V35504Medicare PIN