Healthcare Provider Details

I. General information

NPI: 1902639917
Provider Name (Legal Business Name): GOPENGMD PROF LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2024
Last Update Date: 09/04/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8440 W LAKE MEAD BLVD STE 111
LAS VEGAS NV
89128-7648
US

IV. Provider business mailing address

8440 W LAKE MEAD BLVD STE 111
LAS VEGAS NV
89128-7648
US

V. Phone/Fax

Practice location:
  • Phone: 888-845-7672
  • Fax:
Mailing address:
  • Phone: 888-845-7672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. ANN UGANIZA
Title or Position: BUSINESS ADMINSTRATOR
Credential:
Phone: 702-703-1668