Provider Demographics
NPI:1245234145
Name:LAS VEGAS KIDNEY CLINIC INC.
Entity Type:Organization
Organization Name:LAS VEGAS KIDNEY CLINIC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GALEN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:BSBA
Authorized Official - Phone:702-214-9516
Mailing Address - Street 1:1905 CIVIC CENTER DR
Mailing Address - Street 2:STE 201
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89030-7116
Mailing Address - Country:US
Mailing Address - Phone:702-214-9516
Mailing Address - Fax:702-214-9415
Practice Address - Street 1:1905 CIVIC CENTER DR
Practice Address - Street 2:STE 201
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030-7116
Practice Address - Country:US
Practice Address - Phone:702-214-9516
Practice Address - Fax:702-214-9415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-08
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV3221ESR3261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100501915Medicaid
NV292519Medicare Oscar/Certification