Healthcare Provider Details

I. General information

NPI: 1457447591
Provider Name (Legal Business Name): VEGAS VALLEY PERSONAL CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5016 ALTA DR SUITE # 1
LAS VEGAS NV
89107-3944
US

IV. Provider business mailing address

5016 ALTA DR SUITE # 1
LAS VEGAS NV
89107-3944
US

V. Phone/Fax

Practice location:
  • Phone: 702-870-8855
  • Fax: 702-870-8857
Mailing address:
  • Phone: 702-870-8855
  • Fax: 702-870-8857

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberH1400141B120899
License Number StateNV

VIII. Authorized Official

Name: MS. EMA GOMEZ -MITCHELL
Title or Position: OWNER
Credential:
Phone: 702-870-8855