Provider Demographics
NPI:1245785203
Name:WAGONEER GROUP CARE
Entity Type:Organization
Organization Name:WAGONEER GROUP CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:CLARETE
Authorized Official - Last Name:FINK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-825-6876
Mailing Address - Street 1:3705 WAGONEER DR
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-5917
Mailing Address - Country:US
Mailing Address - Phone:775-409-5675
Mailing Address - Fax:775-800-1836
Practice Address - Street 1:3705 WAGONEER DR
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-5917
Practice Address - Country:US
Practice Address - Phone:775-409-5675
Practice Address - Fax:775-800-1836
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-19
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV9005046915Other9005046915