Healthcare Provider Details

I. General information

NPI: 1861165201
Provider Name (Legal Business Name): GRACE MANAGO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2021
Last Update Date: 07/30/2021
Certification Date: 07/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7375 PRAIRIE FALCON RD STE 120
LAS VEGAS NV
89128-0810
US

IV. Provider business mailing address

7375 PRAIRIE FALCON RD STE 120
LAS VEGAS NV
89128-0810
US

V. Phone/Fax

Practice location:
  • Phone: 702-869-4401
  • Fax: 702-869-9904
Mailing address:
  • Phone: 702-869-4401
  • Fax: 702-869-9904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC3500X
TaxonomyCardiac Rehabilitation Registered Nurse
License Number835448
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: