Provider Demographics
NPI:1114984549
Name:GREAT BASIN SURGICAL CENTER, LLC
Entity Type:Organization
Organization Name:GREAT BASIN SURGICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:CROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-753-5571
Mailing Address - Street 1:855 GOLFCOURSE RD
Mailing Address - Street 2:
Mailing Address - City:ELKO
Mailing Address - State:NV
Mailing Address - Zip Code:89801-3451
Mailing Address - Country:US
Mailing Address - Phone:775-753-4700
Mailing Address - Fax:775-753-4703
Practice Address - Street 1:855 GOLFCOURSE RD
Practice Address - Street 2:
Practice Address - City:ELKO
Practice Address - State:NV
Practice Address - Zip Code:89801-3451
Practice Address - Country:US
Practice Address - Phone:775-753-4700
Practice Address - Fax:775-753-4703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-28
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2172ASC-8261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV004604001Medicaid
NV004604001Medicaid