Provider Demographics
NPI:1326350778
Name:ST. MARY'S CHW PRIMARY CARE PLUS
Entity Type:Organization
Organization Name:ST. MARY'S CHW PRIMARY CARE PLUS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:ELISE
Authorized Official - Middle Name:
Authorized Official - Last Name:GRONHAGEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-770-7351
Mailing Address - Street 1:PO BOX 9035
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89507-9035
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:235 W 6TH ST
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89503-4548
Practice Address - Country:US
Practice Address - Phone:775-770-7351
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-13
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care