1578520896 NPI number — DR. RICHARD J BRALLIAR DO

Table of content: DR. RICHARD J BRALLIAR DO (NPI 1578520896)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578520896 NPI number — DR. RICHARD J BRALLIAR DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRALLIAR
Provider First Name:
RICHARD
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1578520896
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/02/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7930 W SAHARA AVE
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:
89117-1990
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-406-6758
Provider Business Mailing Address Fax Number:
702-852-0348

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2445 FIRE MESA ST
Provider Second Line Business Practice Location Address:
270
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89128-9014
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-876-9330
Provider Business Practice Location Address Fax Number:
702-876-9061
Provider Enumeration Date:
04/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  815 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 002019185 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".




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