Provider Demographics
NPI:1851444079
Name:SOUTH MEADOWS ENDOSCOPY CENTER, LLC
Entity Type:Organization
Organization Name:SOUTH MEADOWS ENDOSCOPY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:HALTERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:775-329-4600
Mailing Address - Street 1:PO BOX 842681
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90084-2660
Mailing Address - Country:US
Mailing Address - Phone:775-329-4600
Mailing Address - Fax:775-324-4314
Practice Address - Street 1:10619 PROFESSIONAL CIR
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89521-5831
Practice Address - Country:US
Practice Address - Phone:775-852-4848
Practice Address - Fax:775-850-5763
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100512981Medicaid