Healthcare Provider Details

I. General information

NPI: 1588929962
Provider Name (Legal Business Name): DAN WRUCK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2012
Last Update Date: 07/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9499 W CHARLESTON BLVD STE 200
LAS VEGAS NV
89117-7150
US

IV. Provider business mailing address

9499 W CHARLESTON BLVD STE 200
LAS VEGAS NV
89117-7150
US

V. Phone/Fax

Practice location:
  • Phone: 702-933-9393
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: