MEDICARE: SPC CAPITAL LLC

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	261QA1903X	Ambulatory Surgical Clinic/Center	4388ASC-0	NV

General Provider Information

NPI Number	:	1194775403
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPC CAPITAL LLC

Provider Business Mailing Address
First Line	:	1569 E FLAMINGO RD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-5131
Country	:	US
Telephone Number	:	702-633-0253
Fax Number	:	702-633-0334

Provider Business Practice Location Address
First Line	:	1569 E FLAMINGO RD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-5131
Country	:	US
Telephone Number	:	702-633-0253
Fax Number	:	702-633-0334

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. JERRY HAWLEY
Credential	:
Telephone Number	:	702-633-0253

Provider Enumeration Date	:	05/10/2006
Last Update Date	:	08/22/2020

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Directions to “SPC CAPITAL LLC ” Practice Location

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