Healthcare Provider Details

I. General information

NPI: 1942587548
Provider Name (Legal Business Name): CONFUZION52
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2011
Last Update Date: 11/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

531 BLACKBIRD KNOLL CT
NORTH LAS VEGAS NV
89084-1316
US

IV. Provider business mailing address

PO BOX 336514
NORTH LAS VEGAS NV
89033-6514
US

V. Phone/Fax

Practice location:
  • Phone: 702-633-9196
  • Fax:
Mailing address:
  • Phone: 702-633-9196
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: EILA R GREGORY
Title or Position: COMMUNITY HEALTH REPRESENTATIVE
Credential:
Phone: 702-633-9196