Healthcare Provider Details

I. General information

NPI: 1922592534
Provider Name (Legal Business Name): JORGE MANZO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2018
Last Update Date: 06/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6330 MCLEOD DR STE 3
LAS VEGAS NV
89120-4431
US

IV. Provider business mailing address

2020 PINTO LN
LAS VEGAS NV
89106-4019
US

V. Phone/Fax

Practice location:
  • Phone: 702-487-5480
  • Fax:
Mailing address:
  • Phone: 702-868-2901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: