Healthcare Provider Details

I. General information

NPI: 1366001950
Provider Name (Legal Business Name): GERARDO A MARIANO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2019
Last Update Date: 06/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4462 FARMCREST DR
LAS VEGAS NV
89121-4906
US

IV. Provider business mailing address

4462 FARMCREST DR
LAS VEGAS NV
89121-4906
US

V. Phone/Fax

Practice location:
  • Phone: 702-433-2879
  • Fax:
Mailing address:
  • Phone: 702-433-2879
  • Fax: 702-433-2879

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number297-AGC-32
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: