Healthcare Provider Details

I. General information

NPI: 1871911875
Provider Name (Legal Business Name): MICOLER, INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2014
Last Update Date: 04/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1715 KUENZLI ST
RENO NV
89502-1117
US

IV. Provider business mailing address

5000 SMITHRIDGE DRIVE D11
RENO NV
89502-5654
US

V. Phone/Fax

Practice location:
  • Phone: 775-857-2876
  • Fax: 775-857-2878
Mailing address:
  • Phone: 775-857-2876
  • Fax: 775-857-2878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code207RI0001X
TaxonomyClinical & Laboratory Immunology (Internal Medicine) Physician
License Number
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number StateNV
# 4
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number
License Number StateNV

VIII. Authorized Official

Name: DAVID LEROY PROTHRO
Title or Position: CEO
Credential: M.D.
Phone: 775-322-4449