Provider Demographics
NPI:1255416491
Name:STATE OF NEVADA
Entity type:Organization
Organization Name:STATE OF NEVADA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHNIII
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:RITTER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:775-684-5031
Mailing Address - Street 1:727 FAIRVIEW DR STE A
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89701-5493
Mailing Address - Country:US
Mailing Address - Phone:775-684-5031
Mailing Address - Fax:775-687-1181
Practice Address - Street 1:1005 MAIN STREET
Practice Address - Street 2:
Practice Address - City:PANACA
Practice Address - State:NV
Practice Address - Zip Code:89042-0000
Practice Address - Country:US
Practice Address - Phone:775-726-3123
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF NEVADA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-26
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251J00000X
NV251J00000X, 251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
No251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV001713906Medicaid
NVFE781AMedicare UPIN
NV001713906Medicaid