=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982155446
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUAN PABLO MOZO TORRES
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/20/2016
-----------------------------------------------------
Last Update Date | 10/20/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2780 S JONES BLVD SUITE 115
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89146-5628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-323-1323
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4650 W OAKEY BLVD APT 2119
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89102-1510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-715-8255
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------