Healthcare Provider Details

I. General information

NPI: 1336720531
Provider Name (Legal Business Name): OGHENETEJIRO ERUSIAFE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2021
Last Update Date: 04/19/2021
Certification Date: 01/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4055 SPENCER ST STE 118
LAS VEGAS NV
89119-5250
US

IV. Provider business mailing address

4055 SPENCER ST STE 118
LAS VEGAS NV
89119-5250
US

V. Phone/Fax

Practice location:
  • Phone: 702-799-9710
  • Fax:
Mailing address:
  • Phone: 702-799-9710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: