=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437158771
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEVADA ORTHOPEDIC & SPINE CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2005
-----------------------------------------------------
Last Update Date | 01/09/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7455 W WASHINGTON AVE #160
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89128-4337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-878-0393
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7455 W WASHINGTON AVE #160
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89128-4337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-878-0393
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL STAFF CREDENTIALING MANAGER
-----------------------------------------------------
Name | MELANIE L LAPOLLA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 702-258-5521
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | C14-00279-3-092590
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------