MEDICARE: BOARD OF REGENTS, NEVADA SYSTEM OF HIGHER EDUCATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1053414862
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOARD OF REGENTS, NEVADA SYSTEM OF HIGHER EDUCATION

Provider Business Mailing Address
First Line	:	1001 SHADOW LN # MS 7413
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89106-4124
Country	:	US
Telephone Number	:	702-774-2661
Fax Number	:	702-774-2610

Provider Business Practice Location Address
First Line	:	1700 W CHARLESTON BLVD BLDG A
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89102-2335
Country	:	US
Telephone Number	:	702-774-2400
Fax Number	:	702-774-2499

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	MS. AMELIA YOLANDA MOLOCHE
Credential	:	DELEGATED OFFICIAL
Telephone Number	:	702-774-2661

Provider Enumeration Date	:	09/07/2006
Last Update Date	:	04/09/2020

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