=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609185172
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MANSKY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2010
-----------------------------------------------------
Last Update Date | 10/01/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9811 W CHARLESTON BLVD STE 2-735
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89117-7528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-257-6727
-----------------------------------------------------
Fax | 877-324-7915
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9811 W CHARLESTON BLVD STE 2-735
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89117-7528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-257-6727
-----------------------------------------------------
Fax | 877-324-7915
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | PETER A MANSKY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 702-257-6727
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084A0401X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Psychiatry & Neurology) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------