Provider Demographics
NPI:1386677367
Name:PEAVINE PODIATRIC PHYSICIANS,LLC
Entity Type:Organization
Organization Name:PEAVINE PODIATRIC PHYSICIANS,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DPM/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:COROLINDA
Authorized Official - Middle Name:SEHELASA
Authorized Official - Last Name:HELU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-746-3338
Mailing Address - Street 1:PO BOX 5981
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89513-5981
Mailing Address - Country:US
Mailing Address - Phone:775-746-3338
Mailing Address - Fax:775-746-3343
Practice Address - Street 1:645 N ARLINGTON AVE
Practice Address - Street 2:STE 660
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89503-4505
Practice Address - Country:US
Practice Address - Phone:775-746-3338
Practice Address - Fax:775-746-3343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV0107174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVCC8579OtherBC/BS PROVIDER NUMBER
NVCC8579OtherBC/BS PROVIDER NUMBER
NVV39676Medicare PIN
NVCC8579OtherBC/BS PROVIDER NUMBER
NVV39678Medicare PIN
NVBH7945566OtherDEA NUMBER
NVU87576Medicare UPIN