Provider Demographics
NPI:1487832085
Name:STATE OF NEVADA
Entity type:Organization
Organization Name:STATE OF NEVADA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:SIRI
Authorized Official - Middle Name:
Authorized Official - Last Name:MCMILLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-684-5018
Mailing Address - Street 1:727 FAIRVIEW DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89701-5795
Mailing Address - Country:US
Mailing Address - Phone:775-687-5018
Mailing Address - Fax:775-687-1181
Practice Address - Street 1:1528 US HIGHWAY 395 N
Practice Address - Street 2:SUITE 100
Practice Address - City:GARDNERVILLE
Practice Address - State:NV
Practice Address - Zip Code:89410-5265
Practice Address - Country:US
Practice Address - Phone:775-782-3671
Practice Address - Fax:775-782-6639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-06
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV005403001Medicaid