Healthcare Provider Details

I. General information

NPI: 1992811491
Provider Name (Legal Business Name): RED ROCK AT MARYLAND PARKWAY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 09/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3061 SOUTH MARYLAND PARKWAY STE 102
LAS VEGAS NV
89109-2298
US

IV. Provider business mailing address

3061 SOUTH MARYLAND PARKWAY STE 102
LAS VEGAS NV
89109-2298
US

V. Phone/Fax

Practice location:
  • Phone: 702-942-4119
  • Fax: 702-942-4134
Mailing address:
  • Phone: 702-942-4119
  • Fax: 702-942-4134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0206X
TaxonomyMammography Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LAVELLE HARDIN
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 615-344-8203