Healthcare Provider Details

I. General information

NPI: 1114064789
Provider Name (Legal Business Name): JAY RUSSELL WAITE IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4755 PASTURE RD
FALLON NV
89496-5000
US

IV. Provider business mailing address

733 ORCHARD DR APT A
FALLON NV
89406-6158
US

V. Phone/Fax

Practice location:
  • Phone: 775-426-3130
  • Fax: 775-426-3133
Mailing address:
  • Phone: 775-426-3130
  • Fax: 775-426-3133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: