Healthcare Provider Details

I. General information

NPI: 1487465795
Provider Name (Legal Business Name): RYAN MIZOGUCHI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2025
Last Update Date: 01/17/2025
Certification Date: 01/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11500 S EASTERN AVE STE 150
HENDERSON NV
89052-5576
US

IV. Provider business mailing address

11500 S EASTERN AVE STE 150
HENDERSON NV
89052-5576
US

V. Phone/Fax

Practice location:
  • Phone: 856-760-0607
  • Fax:
Mailing address:
  • Phone: 856-760-0607
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT4955
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: