Healthcare Provider Details

I. General information

NPI: 1275952186
Provider Name (Legal Business Name): KOWAN FLY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2014
Last Update Date: 04/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 N RAINBOW BLVD # 106-138
LAS VEGAS NV
89107-1189
US

IV. Provider business mailing address

2995 E SUNSET RD UNIT A129
LAS VEGAS NV
89120-2727
US

V. Phone/Fax

Practice location:
  • Phone: 702-586-0880
  • Fax:
Mailing address:
  • Phone: 702-308-9655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: