Provider Demographics
NPI:1770686271
Name:RED ROCK AT MARYLAND PARKWAY LLC
Entity Type:Organization
Organization Name:RED ROCK AT MARYLAND PARKWAY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LAVELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARDIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-344-8203
Mailing Address - Street 1:3061 SOUTH MARYLAND PARKWAY
Mailing Address - Street 2:STE 102
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89109-2298
Mailing Address - Country:US
Mailing Address - Phone:702-942-4119
Mailing Address - Fax:702-942-4134
Practice Address - Street 1:3061 SOUTH MARYLAND PARKWAY
Practice Address - Street 2:STE 102
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109-2298
Practice Address - Country:US
Practice Address - Phone:702-942-4119
Practice Address - Fax:702-942-4134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV102957Medicare PIN