Healthcare Provider Details

I. General information

NPI: 1598222853
Provider Name (Legal Business Name): DAMON ANDRE OGBURN JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2019
Last Update Date: 02/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7351 W CHARLESTON BLVD STE 140
LAS VEGAS NV
89117-1572
US

IV. Provider business mailing address

6573 ASTORVILLE CT
LAS VEGAS NV
89110-2875
US

V. Phone/Fax

Practice location:
  • Phone: 702-808-9668
  • Fax:
Mailing address:
  • Phone: 951-283-9494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: