Healthcare Provider Details

I. General information

NPI: 1003875873
Provider Name (Legal Business Name): WILDCREEK SURGERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2285 GREEN VISTA DR
SPARKS NV
89431-8532
US

IV. Provider business mailing address

2285 GREEN VISTA DR
SPARKS NV
89431-8532
US

V. Phone/Fax

Practice location:
  • Phone: 775-674-1110
  • Fax: 775-674-1114
Mailing address:
  • Phone: 775-674-1110
  • Fax: 775-674-1114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number1830ASC-8
License Number StateNV

VIII. Authorized Official

Name: DOUGLAS K. DEVRIES
Title or Position: OWNER
Credential: O.D.
Phone: 775-674-1110