MEDICARE: GAMBOA LLC

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	111N00000X	Chiropractor	B00861	NV

General Provider Information

NPI Number	:	1437370160
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GAMBOA LLC

Provider Business Mailing Address
First Line	:	3230 E CHARLESTON BLVD
Second Line	:	SUITE 109
City	:	LAS VEGAS
State	:	NV
Zip	:	89104-6626
Country	:	US
Telephone Number	:	702-478-6914
Fax Number	:	702-478-6915

Provider Business Practice Location Address
First Line	:	3230 E CHARLESTON BLVD
Second Line	:	SUITE 109
City	:	LAS VEGAS
State	:	NV
Zip	:	89104-6626
Country	:	US
Telephone Number	:	702-478-6914
Fax Number	:	702-478-6915

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MIRNA GAMBOA
Credential	:	D.C.
Telephone Number	:	702-478-6914

Provider Enumeration Date	:	05/01/2007
Last Update Date	:	08/22/2020

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