Provider Demographics
NPI:1740481837
Name:SOUTH VALLEY PEDIATRIC CENTER
Entity type:Organization
Organization Name:SOUTH VALLEY PEDIATRIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GALE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:KOCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-492-0004
Mailing Address - Street 1:2610 W HORIZON RIDGE PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-2869
Mailing Address - Country:US
Mailing Address - Phone:702-492-0004
Mailing Address - Fax:702-492-0006
Practice Address - Street 1:2610 W HORIZON RIDGE PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-2869
Practice Address - Country:US
Practice Address - Phone:702-492-0004
Practice Address - Fax:702-492-0006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVAPN000878363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty