Provider Demographics
NPI:1811606189
Name:3LG VENTURES INC
Entity type:Organization
Organization Name:3LG VENTURES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-522-1779
Mailing Address - Street 1:1157 N BLUE MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:BLANDING
Mailing Address - State:UT
Mailing Address - Zip Code:84511-2123
Mailing Address - Country:US
Mailing Address - Phone:575-312-6951
Mailing Address - Fax:
Practice Address - Street 1:1077 NEW RIVER PKWY
Practice Address - Street 2:
Practice Address - City:FALLON
Practice Address - State:NV
Practice Address - Zip Code:89406-6894
Practice Address - Country:US
Practice Address - Phone:775-428-2747
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-16
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care