Healthcare Provider Details

I. General information

NPI: 1740688100
Provider Name (Legal Business Name): DIAGNOSTICAID
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2014
Last Update Date: 12/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 N RAINBOW BLVD STE 300
LAS VEGAS NV
89107-1061
US

IV. Provider business mailing address

500 N RAINBOW BLVD STE 300
LAS VEGAS NV
89107-1061
US

V. Phone/Fax

Practice location:
  • Phone: 702-807-7443
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number
License Number State

VIII. Authorized Official

Name: MARIA BROWN
Title or Position: DIRECTOR
Credential:
Phone: 702-807-7443