=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306317730
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMUNITY CARE SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2018
-----------------------------------------------------
Last Update Date | 06/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 75 PRINGLE WAY STE 801
-----------------------------------------------------
City | RENO
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89502-8400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-982-4000
-----------------------------------------------------
Fax | 775-982-2821
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1155 MILL ST # M14
-----------------------------------------------------
City | RENO
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89502-1576
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-982-5262
-----------------------------------------------------
Fax | 775-982-5496
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO ACUTE CARE
-----------------------------------------------------
Name | MR. BRETT MOORE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 775-982-6343
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207SG0202X
-----------------------------------------------------
Taxonomy Name | Clinical Biochemical Genetics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207RX0202X
-----------------------------------------------------
Taxonomy Name | Medical Oncology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207RH0003X
-----------------------------------------------------
Taxonomy Name | Hematology & Oncology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------