Basic Information
Provider Information | |||||||||
NPI: | 1083669196 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SPECIALTY ASC LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SURGICAL ARTS CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 9499 W CHARLESTON BLVD | ||||||||
Address2: | SUITE 250 | ||||||||
City: | LAS VEGAS | ||||||||
State: | NV | ||||||||
PostalCode: | 891177147 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7029333600 | ||||||||
FaxNumber: | 7029333601 | ||||||||
Practice Location | |||||||||
Address1: | 9499 W CHARLESTON BLVD | ||||||||
Address2: | SUITE 250 | ||||||||
City: | LAS VEGAS | ||||||||
State: | NV | ||||||||
PostalCode: | 891177147 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7029333600 | ||||||||
FaxNumber: | 7029333601 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/24/2006 | ||||||||
LastUpdateDate: | 03/03/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BENNION | ||||||||
AuthorizedOfficialFirstName: | MICHELLE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 7029333600 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 3406ASC-8 | NV | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
ID | Type | State | Issuer | Description | 29C0001049 | 01 | NV | MEDICARE DMERC | OTHER | 4602060 | 05 | NV |   | MEDICAID |