Healthcare Provider Details

I. General information

NPI: 1790514701
Provider Name (Legal Business Name): NICHOLAS JAMES GAMBOA RBT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2024
Last Update Date: 07/29/2024
Certification Date: 07/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9089 S PECOS RD
HENDERSON NV
89074-7183
US

IV. Provider business mailing address

1608 STARRIDGE WAY
LAS VEGAS NV
89142-1175
US

V. Phone/Fax

Practice location:
  • Phone: 702-680-1526
  • Fax:
Mailing address:
  • Phone: 702-376-2809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberRBT-23-309390
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: