Provider Demographics
NPI:1134532773
Name:PRESTIGE PRIMARY PROVIDERS
Entity type:Organization
Organization Name:PRESTIGE PRIMARY PROVIDERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:OSBORNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-762-3383
Mailing Address - Street 1:2305 RIDGE FIELD TRL
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89523-6804
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2305 RIDGE FIELD TRL
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89523-6804
Practice Address - Country:US
Practice Address - Phone:775-762-3383
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-10
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV20141368596261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care