MEDICARE: PREVENTION GAMBLER FOUNDATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1720836570
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREVENTION GAMBLER FOUNDATION

Provider Business Mailing Address
First Line	:	1027 S RAINBOW BLVD STE 162
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89145-6232
Country	:	US
Telephone Number	:	954-860-3216
Fax Number	:

Provider Business Practice Location Address
First Line	:	6285 ANGORA PEAK LN
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89115-1662
Country	:	US
Telephone Number	:	954-860-3216
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MS. RITA G DOMINGUEZ
Credential	:	GAMBLING COUNSELOR
Telephone Number	:	954-860-3216

Provider Enumeration Date	:	05/07/2024
Last Update Date	:	05/07/2024

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Directions to “PREVENTION GAMBLER FOUNDATION ” Practice Location

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