Provider Demographics
NPI:1235327909
Name:MOUNTAIN VALLEY PHYSICIAN GROUP, LLC
Entity Type:Organization
Organization Name:MOUNTAIN VALLEY PHYSICIAN GROUP, LLC
Other - Org Name:MOUNTAIN VALLEY PHYSICIAN GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:STODDARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-751-7519
Mailing Address - Street 1:360 S LOLA LN
Mailing Address - Street 2:
Mailing Address - City:PAHRUMP
Mailing Address - State:NV
Mailing Address - Zip Code:89048-0884
Mailing Address - Country:US
Mailing Address - Phone:775-751-7580
Mailing Address - Fax:775-751-7820
Practice Address - Street 1:360 S LOLA LN
Practice Address - Street 2:
Practice Address - City:PAHRUMP
Practice Address - State:NV
Practice Address - Zip Code:89048-0884
Practice Address - Country:US
Practice Address - Phone:775-751-7580
Practice Address - Fax:775-751-7820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1235327909Medicaid
NV1235327909Medicaid