Provider Demographics
NPI:1417114166
Name:STONECREEK SURGERY CENTER LLC
Entity Type:Organization
Organization Name:STONECREEK SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-202-4776
Mailing Address - Street 1:2850 W HORIZON RIDGE PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-4395
Mailing Address - Country:US
Mailing Address - Phone:702-202-4776
Mailing Address - Fax:
Practice Address - Street 1:5915 S RAINBOW BLVD STE 108
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89118-2558
Practice Address - Country:US
Practice Address - Phone:702-227-7959
Practice Address - Fax:702-227-6344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-20
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1417114166Medicaid