Healthcare Provider Details

I. General information

NPI: 1578971065
Provider Name (Legal Business Name): GROVER BERRY III AA MANAGEMENT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2014
Last Update Date: 07/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3660 N RANCHO DR STE 113
LAS VEGAS NV
89130-3188
US

IV. Provider business mailing address

3360 N RANCHO DR. STE.113
LAS VEGAS NV
89130
US

V. Phone/Fax

Practice location:
  • Phone: 702-982-2928
  • Fax:
Mailing address:
  • Phone: 702-982-2928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: