Provider Demographics
NPI:1710948070
Name:SAINT MARY'S MULTI-SPECIALTY CLINIC, INC.
Entity Type:Organization
Organization Name:SAINT MARY'S MULTI-SPECIALTY CLINIC, INC.
Other - Org Name:SAINT MARY'S MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DAVE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHALLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-770-6679
Mailing Address - Street 1:645 N ARLINGTON AVE STE 555
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89503-4452
Mailing Address - Country:US
Mailing Address - Phone:775-770-7661
Mailing Address - Fax:775-770-7368
Practice Address - Street 1:1510 MEADOW WOOD LN
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-8503
Practice Address - Country:US
Practice Address - Phone:775-770-7210
Practice Address - Fax:775-770-7211
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAINT MARY'S MULTI-SPECIALTY CLINIC, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-03-28
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100507825Medicaid
61372200OtherDEPT OF LABOR - WORK COMP
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