Provider Demographics
NPI:1245782861
Name:SMOKE RANCH SPECIALISTS LLC
Entity Type:Organization
Organization Name:SMOKE RANCH SPECIALISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROSA
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-839-4821
Mailing Address - Street 1:7140 SMOKE RANCH RD
Mailing Address - Street 2:STE 150
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-3157
Mailing Address - Country:US
Mailing Address - Phone:702-839-4825
Mailing Address - Fax:702-998-2198
Practice Address - Street 1:7140 SMOKE RANCH RD
Practice Address - Street 2:STE 150
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-3157
Practice Address - Country:US
Practice Address - Phone:702-839-4825
Practice Address - Fax:702-998-2198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-31
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty