Provider Demographics
NPI:1538129549
Name:SOUTH LYON HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:SOUTH LYON HEALTH CENTER, INC.
Other - Org Name:SOUTH LYON MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL STAFF COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:KYLEE
Authorized Official - Middle Name:
Authorized Official - Last Name:FOWLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-463-6491
Mailing Address - Street 1:213 S WHITACRE ST
Mailing Address - Street 2:
Mailing Address - City:YERINGTON
Mailing Address - State:NV
Mailing Address - Zip Code:89447-2561
Mailing Address - Country:US
Mailing Address - Phone:775-463-2301
Mailing Address - Fax:
Practice Address - Street 1:445 STATE ROUTE 338
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:NV
Practice Address - Zip Code:89444-9711
Practice Address - Country:US
Practice Address - Phone:775-465-2587
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-24
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV3380RHC-5208D00000X
261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV001510005Medicaid
NV293978Medicare Oscar/Certification