=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659680635
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SILVER STATE CARDIOLOGY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2010
-----------------------------------------------------
Last Update Date | 11/19/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4200 W CHARLESTON BLVD BLDG A
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89102-1625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-683-7876
-----------------------------------------------------
Fax | 702-331-5764
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4200 W CHARLESTON BLVD BLDG A
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89102-1625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-683-7876
-----------------------------------------------------
Fax | 702-331-5764
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/OFFICER
-----------------------------------------------------
Name | JOSE AQUINO
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 702-270-2721
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | 9278
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------