Healthcare Provider Details

I. General information

NPI: 1083987630
Provider Name (Legal Business Name): PUSO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2012
Last Update Date: 09/10/2021
Certification Date: 09/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 S RANCHO DR STE A2
LAS VEGAS NV
89106-3870
US

IV. Provider business mailing address

801 S RANCHO DR STE A2
LAS VEGAS NV
89106-3870
US

V. Phone/Fax

Practice location:
  • Phone: 702-483-3630
  • Fax: 800-579-9591
Mailing address:
  • Phone: 702-483-3630
  • Fax: 800-579-9591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: SALVADOR GARCIA BORROMEO III
Title or Position: OWNER
Credential: MD
Phone: 702-683-7876