Healthcare Provider Details

I. General information

NPI: 1134635097
Provider Name (Legal Business Name): MIVIP REGIONAL SURGERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2017
Last Update Date: 09/16/2022
Certification Date: 09/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5950 S DURANGO DR STE 101
LAS VEGAS NV
89113
US

IV. Provider business mailing address

5950 S DURANGO DR STE 101
LAS VEGAS NV
89113-2270
US

V. Phone/Fax

Practice location:
  • Phone: 702-478-7271
  • Fax: 702-478-8945
Mailing address:
  • Phone: 702-726-4000
  • Fax: 702-726-4099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. ROLANDA JOHNSON
Title or Position: ADMINISTRATOR
Credential:
Phone: 702-478-7271