Healthcare Provider Details

I. General information

NPI: 1497120059
Provider Name (Legal Business Name): MR. DAVID OMAR MANGUAL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2015
Last Update Date: 12/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6787 W TROPICANA AVE STE 120B
LAS VEGAS NV
89103-4762
US

IV. Provider business mailing address

6787 W TROPICANA AVE STE 120B
LAS VEGAS NV
89103-4762
US

V. Phone/Fax

Practice location:
  • Phone: 702-659-8827
  • Fax: 702-852-0984
Mailing address:
  • Phone: 702-659-8827
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: