Healthcare Provider Details

I. General information

NPI: 1487063681
Provider Name (Legal Business Name): SOPE JR FAGA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2014
Last Update Date: 08/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 E BRIDGER AVE STE 202
LAS VEGAS NV
89101-5916
US

IV. Provider business mailing address

400 SKY ROAD
INDIAN SPRINGS NV
89018
US

V. Phone/Fax

Practice location:
  • Phone: 702-685-0877
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: