Healthcare Provider Details

I. General information

NPI: 1124454889
Provider Name (Legal Business Name): GARRY KUNICKI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2013
Last Update Date: 09/20/2023
Certification Date: 09/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3931 BLUE CORAL DR
N LAS VEGAS NV
89032-3465
US

IV. Provider business mailing address

3931 BLUE CORAL DR
N LAS VEGAS NV
89032-3465
US

V. Phone/Fax

Practice location:
  • Phone: 702-610-7416
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2472E0500X
TaxonomyEEG Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: