Healthcare Provider Details

I. General information

NPI: 1467603878
Provider Name (Legal Business Name): COMMUNITY CARE HEALTH PLAN OF NEVADA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2008
Last Update Date: 05/17/2021
Certification Date: 05/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9133 WEST RUSSELL ROAD BUILDING 9
LAS VEGAS NV
89148-8351
US

IV. Provider business mailing address

9133 WEST RUSSELL ROAD BUILDING 9
LAS VEGAS NV
89148-8351
US

V. Phone/Fax

Practice location:
  • Phone: 702-545-9842
  • Fax: 702-360-0755
Mailing address:
  • Phone: 702-545-9842
  • Fax: 702-360-0755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number17690
License Number StateNV

VIII. Authorized Official

Name: LISA J BOGARD
Title or Position: PRESIDENT AND CEO
Credential:
Phone: 702-545-9842