Healthcare Provider Details

I. General information

NPI: 1720949746
Provider Name (Legal Business Name): PIONEER PEDIATRICS WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2025
Last Update Date: 11/19/2025
Certification Date: 11/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4840 E BONANZA RD STE 5
LAS VEGAS NV
89110-3453
US

IV. Provider business mailing address

4840 E BONANZA RD STE 5
LAS VEGAS NV
89110-3453
US

V. Phone/Fax

Practice location:
  • Phone: 702-370-7842
  • Fax:
Mailing address:
  • Phone: 702-370-7842
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: PRISCILLA VERNICE OTOO-ADJORLOLO
Title or Position: CLINICAL DIRECTOR
Credential: LCSW
Phone: 702-370-7842