Provider Demographics
NPI:1073087680
Name:BURN AND RECONSTRUCTIVE CENTERS OF NEVADA, LLC
Entity Type:Organization
Organization Name:BURN AND RECONSTRUCTIVE CENTERS OF NEVADA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MD
Authorized Official - Prefix:
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:FAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-863-9595
Mailing Address - Street 1:PO BOX 12357
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30914-2357
Mailing Address - Country:US
Mailing Address - Phone:706-863-9595
Mailing Address - Fax:706-868-8375
Practice Address - Street 1:3186 S MARYLAND PKWY
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109-2317
Practice Address - Country:US
Practice Address - Phone:706-863-9595
Practice Address - Fax:706-868-8375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-16
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty