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
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261QA1903X3406ASC-8NVY Ambulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical

ID Information
IDTypeStateIssuerDescription
29C000104901NVMEDICARE DMERCOTHER
460206005NV MEDICAID


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