Healthcare Provider Details

I. General information

NPI: 1740843150
Provider Name (Legal Business Name): ROY MATTHEW GINGRICH OT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2019
Last Update Date: 12/22/2021
Certification Date: 12/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 E DESERT INN RD STE 200
LAS VEGAS NV
89121-3632
US

IV. Provider business mailing address

2800 E DESERT INN RD STE 200
LAS VEGAS NV
89121-3632
US

V. Phone/Fax

Practice location:
  • Phone: 702-294-7499
  • Fax: 702-735-0097
Mailing address:
  • Phone: 702-294-7499
  • Fax: 702-735-0097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT-2190
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number108506
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: