=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245234145
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAS VEGAS KIDNEY CLINIC INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2005
-----------------------------------------------------
Last Update Date | 06/06/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1905 CIVIC CENTER DR STE 201
-----------------------------------------------------
City | NORTH LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89030-7116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-214-9516
-----------------------------------------------------
Fax | 702-214-9415
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1905 CIVIC CENTER DR STE 201
-----------------------------------------------------
City | NORTH LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89030-7116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-214-9516
-----------------------------------------------------
Fax | 702-214-9415
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. GALEN ROBERT BENNETT
-----------------------------------------------------
Credential | BSBA
-----------------------------------------------------
Telephone | 702-214-9516
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | 3221ESR3
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------