Healthcare Provider Details

I. General information

NPI: 1184278376
Provider Name (Legal Business Name): ERIK JACKSON GIMLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2019
Last Update Date: 07/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 MOONGATE RD # B
CORRALES NM
87048-8350
US

IV. Provider business mailing address

9811 W CHARLESTON BLVD # 2-641
LAS VEGAS NV
89117-7528
US

V. Phone/Fax

Practice location:
  • Phone: 508-930-5693
  • Fax:
Mailing address:
  • Phone: 855-864-4322
  • Fax: 866-540-8267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: