Provider Demographics
NPI:1982677191
Name:LAS VEGAS EAST OPHTHALMOLOGY ASC LLC
Entity Type:Organization
Organization Name:LAS VEGAS EAST OPHTHALMOLOGY ASC LLC
Other - Org Name:SHEPHERD EYE SURGICENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-202-4776
Mailing Address - Street 1:50 S STEPHANIE ST STE 101
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89012-5731
Mailing Address - Country:US
Mailing Address - Phone:702-202-4776
Mailing Address - Fax:702-202-6110
Practice Address - Street 1:3575 PECOS MCLEOD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-3803
Practice Address - Country:US
Practice Address - Phone:702-731-2088
Practice Address - Fax:702-734-7836
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-08
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV485ASC-12261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV4602450Medicaid
NV4602450Medicaid
NV=========OtherTRIWEST HEALTHCARE ALLIAN
NV4602450Medicaid