Basic Information
| Provider Information | |||||||||
| NPI: | 1154604700 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUPPLEMENTAL HEALTHCARE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SHC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5135 MARSHALL ISLAND CT | ||||||||
| Address2: | |||||||||
| City: | NORTH LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890310962 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024949323 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1120 N TOWN CENTER DR STE 120 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891446302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9999999999 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2011 | ||||||||
| LastUpdateDate: | 09/21/2011 | ||||||||
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| AuthorizedOfficialLastName: | KAISERMAN | ||||||||
| AuthorizedOfficialFirstName: | BRAIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SUPERVISOR/MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9999999999 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283X00000X | RC1676 | NV | N | Hospitals | Rehabilitation Hospital | 251J00000X | RC1676 | NV | Y | Agencies | Nursing Care |
No ID Information.