Healthcare Provider Details

I. General information

NPI: 1083669196
Provider Name (Legal Business Name): SPECIALTY ASC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 03/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9499 W CHARLESTON BLVD SUITE 250
LAS VEGAS NV
89117-7147
US

IV. Provider business mailing address

9499 W CHARLESTON BLVD SUITE 250
LAS VEGAS NV
89117-7147
US

V. Phone/Fax

Practice location:
  • Phone: 702-933-3600
  • Fax: 702-933-3601
Mailing address:
  • Phone: 702-933-3600
  • Fax: 702-933-3601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number3406ASC-8
License Number StateNV

VIII. Authorized Official

Name: MICHELLE BENNION
Title or Position: ADMINISTRATOR
Credential:
Phone: 702-933-3600