MEDICARE: REINIER MOLA GANDOL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3747P1801X	Personal Care Attendant
2	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1407522014
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REINIER MOLA GANDOL

Provider Business Mailing Address
First Line	:	4820 EL ESCORIAL DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-6805
Country	:	US
Telephone Number	:	702-510-9229
Fax Number	:

Provider Business Practice Location Address
First Line	:	4820 EL ESCORIAL DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-6805
Country	:	US
Telephone Number	:	702-510-9229
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/23/2021
Last Update Date	:	12/14/2022

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