=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225414246
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LV SURGERY CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/31/2015
-----------------------------------------------------
Last Update Date | 11/02/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7315 S. PECOS RD. SUITE 103
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-855-0550
-----------------------------------------------------
Fax | 702-855-0650
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7315 S PECOS RD SUITE 103
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89120-3768
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | NOEL FAJARDO
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 702-855-0550
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------