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General NPI Number Information
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NPI Number | 1134532773
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Entity Type | Organization
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Legal Business Name | PRESTIGE PRIMARY PROVIDERS
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Dates
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Enumeration Date | 06/10/2014
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Last Update Date | 06/10/2014
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Provider Practice Location Address
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Address Line | 2305 RIDGE FIELD TRL
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City | RENO
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State | NV
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Zip | 89523-6804
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Country | US
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Telephone | 775-762-3383
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Fax |
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Provider Business Mailing Address
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Address Line | 2305 RIDGE FIELD TRL
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City | RENO
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State | NV
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Zip | 89523-6804
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | TIMOTHY SCOTT OSBORNE
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Credential |
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Telephone | 775-762-3383
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | NV20141368596
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License Number State | NV
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