MEDICARE: MR. JACK TARANGO III MASTERS

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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1801220785
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JACK TARANGO III MASTERS

Provider Business Mailing Address
First Line	:	6413 WHITE TIGER CT
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89130-1875
Country	:	US
Telephone Number	:	310-780-2936
Fax Number	:

Provider Business Practice Location Address
First Line	:	570 W CHEYENNE AVE STE 210
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89030-3983
Country	:	US
Telephone Number	:	702-754-3900
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/27/2013
Last Update Date	:	08/27/2013

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