Healthcare Provider Details

I. General information

NPI: 1114984549
Provider Name (Legal Business Name): GREAT BASIN SURGICAL CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2006
Last Update Date: 03/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 GOLFCOURSE RD
ELKO NV
89801-3451
US

IV. Provider business mailing address

855 GOLFCOURSE RD
ELKO NV
89801-3451
US

V. Phone/Fax

Practice location:
  • Phone: 775-753-4700
  • Fax: 775-753-4703
Mailing address:
  • Phone: 775-753-4700
  • Fax: 775-753-4703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number2172ASC-8
License Number StateNV

VIII. Authorized Official

Name: MS. SUSANNE CROSS
Title or Position: OFFICE MANAGER
Credential:
Phone: 775-753-5571