Healthcare Provider Details

I. General information

NPI: 1750827580
Provider Name (Legal Business Name): PLATINUM SURGICAL ASSISTANTS OF LAS VEGAS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2017
Last Update Date: 01/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4140 INGLEWOOD POINT ST
NORTH LAS VEGAS NV
89032-1147
US

IV. Provider business mailing address

4140 INGLEWOOD POINT ST
NORTH LAS VEGAS NV
89032-1147
US

V. Phone/Fax

Practice location:
  • Phone: 702-325-8928
  • Fax:
Mailing address:
  • Phone: 702-325-8928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code156FX1101X
TaxonomyOphthalmic Assistant
License Number171630
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number171630
License Number State
# 4
Primary TaxonomyN
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number171630
License Number StateNV
# 5
Primary TaxonomyN
Taxonomy Code246ZX2200X
TaxonomyOrthopedic Assistant
License Number171630
License Number StateNV
# 6
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number171630
License Number StateNV

VIII. Authorized Official

Name: MR. VERN VONTRICE PALMER
Title or Position: CEO
Credential: CSFA
Phone: 702-325-8928