Provider Demographics
NPI:1164487930
Name:SUNSHINE VALLEY HEALTH CARE-WESLEY J. ROBERTSON M.D. PROF. CORP.
Entity Type:Organization
Organization Name:SUNSHINE VALLEY HEALTH CARE-WESLEY J. ROBERTSON M.D. PROF. CORP.
Other - Org Name:SUNSHINE VALLEY PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-363-3000
Mailing Address - Street 1:653 N TOWN CENTER DR
Mailing Address - Street 2:SUITE 106
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89144-0514
Mailing Address - Country:US
Mailing Address - Phone:702-363-3000
Mailing Address - Fax:702-363-3161
Practice Address - Street 1:653 N TOWN CENTER DR
Practice Address - Street 2:SUITE 106
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89144-0514
Practice Address - Country:US
Practice Address - Phone:702-363-3000
Practice Address - Fax:702-363-3161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-17
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV7487208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002019564Medicaid
NV100503771Medicaid
NV100502879Medicaid
NV002018144Medicaid