Healthcare Provider Details

I. General information

NPI: 1083612741
Provider Name (Legal Business Name): STATE OF NEVADA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 08/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 VETERANS MEMORIAL DRIVE
BOULDER CITY NV
89005
US

IV. Provider business mailing address

100 VETERANS MEMORIAL DRIVE
BOULDER CITY NV
89005
US

V. Phone/Fax

Practice location:
  • Phone: 702-332-6713
  • Fax: 702-332-6762
Mailing address:
  • Phone: 702-332-6713
  • Fax: 702-332-6762

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number2984 SNF-6
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number2984 SNF-6
License Number StateNV
# 3
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2984 SNF-6
License Number StateNV

VIII. Authorized Official

Name: MR. FRANK S BELLINGER
Title or Position: ADMINISTRATOR
Credential:
Phone: 702-332-6713