Provider Demographics
NPI:1316169980
Name:SWANLAKE MEDICAL CENTER
Entity type:Organization
Organization Name:SWANLAKE MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:R
Authorized Official - Last Name:BRUCE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-765-5253
Mailing Address - Street 1:3330 S HUALAPAI WAY
Mailing Address - Street 2:SUITE #120
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-7716
Mailing Address - Country:US
Mailing Address - Phone:702-765-5253
Mailing Address - Fax:702-765-5354
Practice Address - Street 1:3330 S HUALAPAI WAY
Practice Address - Street 2:SUITE #120
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-7716
Practice Address - Country:US
Practice Address - Phone:702-765-5253
Practice Address - Fax:702-765-5354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2010-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV9484207R00000X
NV8652208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV36259Medicare PIN