Healthcare Provider Details

I. General information

NPI: 1760195796
Provider Name (Legal Business Name): LUIS CARLOS O ORTEGA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2023
Last Update Date: 06/21/2023
Certification Date: 06/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 S TONOPAH DR
LAS VEGAS NV
89106-4029
US

IV. Provider business mailing address

620 S TONOPAH DR
LAS VEGAS NV
89106-4029
US

V. Phone/Fax

Practice location:
  • Phone: 702-413-1391
  • Fax: 702-413-1392
Mailing address:
  • Phone: 702-413-1391
  • Fax: 702-413-1392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. LUISA CARLA ORTEGA
Title or Position: SECRETARY
Credential:
Phone: 702-629-0131