Provider Demographics
NPI:1689013161
Name:FREMONT EMERGENCY SERVICES MANDAVIA LTD
Entity Type:Organization
Organization Name:FREMONT EMERGENCY SERVICES MANDAVIA LTD
Other - Org Name:FREMONT EMERGENCY SERVICES (HENNER AND SEARS) LTD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DIRECTOR PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:HARDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:925-251-6901
Mailing Address - Street 1:PO BOX 638972
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-8972
Mailing Address - Country:US
Mailing Address - Phone:925-924-1600
Mailing Address - Fax:
Practice Address - Street 1:3001 SAINT ROSE PKWY
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-3839
Practice Address - Country:US
Practice Address - Phone:702-616-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-18
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1689013161Medicaid