Healthcare Provider Details

I. General information

NPI: 1982947701
Provider Name (Legal Business Name): A-GRAV 1 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2013
Last Update Date: 03/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

365 E WINDMILL LN
LAS VEGAS NV
89123-1807
US

IV. Provider business mailing address

2375 E TROPICANA AVE # 271
LAS VEGAS NV
89119-6564
US

V. Phone/Fax

Practice location:
  • Phone: 702-675-3569
  • Fax: 702-701-9413
Mailing address:
  • Phone: 702-675-3569
  • Fax: 702-701-9413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. DENNIS LAVERN DUBOIS
Title or Position: MANAGING MEMBER
Credential:
Phone: 702-373-8151