Healthcare Provider Details

I. General information

NPI: 1699738872
Provider Name (Legal Business Name): NORTHERN NEVADA AMBULATORY SURGICAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2006
Last Update Date: 06/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5411 KIETZKE LANE
RENO NV
89511
US

IV. Provider business mailing address

5411 KIETZKE LANE
RENO NV
89511
US

V. Phone/Fax

Practice location:
  • Phone: 775-954-0600
  • Fax: 775-954-0612
Mailing address:
  • Phone: 775-954-0600
  • Fax: 775-954-0612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number2048ASC-12
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number2048ASC-19
License Number StateNV

VIII. Authorized Official

Name: MRS. STACEY INGRAM
Title or Position: ADMINISTRATOR
Credential:
Phone: 775-954-0600