Provider Demographics
NPI:1487680815
Name:BOARD OF REGENTS, NEVADA SYSTEM OF HIGHER EDUCATION
Entity Type:Organization
Organization Name:BOARD OF REGENTS, NEVADA SYSTEM OF HIGHER EDUCATION
Other - Org Name:UNLV GENERAL PRACTICE RESIDENCY
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR OF CLINICAL BUSINESS SVCS.
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:702-774-2819
Mailing Address - Street 1:1001 SHADOW LANE
Mailing Address - Street 2:MS 7413
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-4124
Mailing Address - Country:US
Mailing Address - Phone:702-774-2400
Mailing Address - Fax:702-774-2499
Practice Address - Street 1:1707 W. CHARLESTON BLVD.
Practice Address - Street 2:SUITE 210
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-2351
Practice Address - Country:US
Practice Address - Phone:702-671-5175
Practice Address - Fax:702-474-9617
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOARD OF REGENTS, NV SYSTEM OF HIGHER EDUCATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-25
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002202240Medicaid