MEDICARE: DR. MIRNA GAMBOA D.C.

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	B01028	NV

General Provider Information

NPI Number	:	1528101375
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MIRNA GAMBOA D.C.

Provider Business Mailing Address
First Line	:	3230 E CHARLESTON BLVD STE 109
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89104-6625
Country	:	US
Telephone Number	:	702-478-6914
Fax Number	:	702-478-6915

Provider Business Practice Location Address
First Line	:	3230 E CHARLESTON BLVD STE 109
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89104-6625
Country	:	US
Telephone Number	:	702-478-6914
Fax Number	:	702-478-6915

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

Provider Enumeration Date	:	02/14/2007
Last Update Date	:	07/08/2007

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