MEDICARE: MIWAH KO CCC

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	235Z00000X	Speech-Language Pathologist

General Provider Information

NPI Number	:	1841793353
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIWAH KO CCC

Provider Business Mailing Address
First Line	:	5155 BLUE DIAMOND RD STE 102
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89139-7698
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5155 BLUE DIAMOND RD STE 102
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89139-7698
Country	:	US
Telephone Number	:	702-530-2532
Fax Number	:

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

Provider Enumeration Date	:	03/10/2018
Last Update Date	:	05/16/2024

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Directions to “ MIWAH KO CCC” Practice Location

Language	Start Address	Practice Location

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