Provider Demographics
NPI:1205564663
Name:QUEENSRIDGE CARDIOLOGY CENTER LLC
Entity type:Organization
Organization Name:QUEENSRIDGE CARDIOLOGY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:LERMA
Authorized Official - Suffix:
Authorized Official - Credentials:MS,MBA,CASC
Authorized Official - Phone:702-589-9250
Mailing Address - Street 1:2779 W HORIZON RIDGE PKWY STE 140
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-4186
Mailing Address - Country:US
Mailing Address - Phone:702-589-9250
Mailing Address - Fax:702-589-9257
Practice Address - Street 1:10040 ALTA DRIVE
Practice Address - Street 2:SUITE 250
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89145-8905
Practice Address - Country:US
Practice Address - Phone:702-589-9250
Practice Address - Fax:702-589-9257
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-12
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1043652906OtherCOMMERCIAL PAYRORS