1982947701 NPI number — A-GRAV 1 LLC

Table of content: (NPI 1982947701)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982947701 NPI number — A-GRAV 1 LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
A-GRAV 1 LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MOON WALK CARDIO
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1982947701
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/29/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2375 E TROPICANA AVE # 271
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89119-6564
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-675-3569
Provider Business Mailing Address Fax Number:
702-701-9413

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
365 E WINDMILL LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89123-1807
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-675-3569
Provider Business Practice Location Address Fax Number:
702-701-9413
Provider Enumeration Date:
03/29/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DUBOIS
Authorized Official First Name:
DENNIS
Authorized Official Middle Name:
LAVERN
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
702-373-8151

Provider Taxonomy Codes

  • Taxonomy code: 261QH0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QP2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)