Healthcare Provider Details

I. General information

NPI: 1760501852
Provider Name (Legal Business Name): GARY BOGK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1590 W SUNSET RD
HENDERSON NV
89014-6633
US

IV. Provider business mailing address

6161 W CHARLESTON BLVD
LAS VEGAS NV
89146-1126
US

V. Phone/Fax

Practice location:
  • Phone: 702-486-6700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1300X
TaxonomyPsychiatric Pharmacist
License Number10994
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: