Healthcare Provider Details

I. General information

NPI: 1245720010
Provider Name (Legal Business Name): TAG 2 COLLABORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2018
Last Update Date: 04/03/2026
Certification Date: 04/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5860 WYNN RD STE B
LAS VEGAS NV
89118-3063
US

IV. Provider business mailing address

5860 WYNN RD STE B
LAS VEGAS NV
89118-3063
US

V. Phone/Fax

Practice location:
  • Phone: 732-515-5511
  • Fax:
Mailing address:
  • Phone: 732-515-5511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: JACK MADER
Title or Position: PRESIDENT
Credential:
Phone: 732-515-5511