Healthcare Provider Details

I. General information

NPI: 1417301532
Provider Name (Legal Business Name): EDMUND ROBERTO SANTOS BCABA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2016
Last Update Date: 06/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

731 MALL RING CIR SUITE 215
HENDERSON NV
89014-6683
US

IV. Provider business mailing address

731 MALL RING CIR SUITE 215
HENDERSON NV
89014-6683
US

V. Phone/Fax

Practice location:
  • Phone: 702-547-6971
  • Fax: 702-547-6948
Mailing address:
  • Phone: 702-547-6971
  • Fax: 702-547-6948

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberRBT-15-02170
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number0-19-9614
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: