1922008523 NPI number — RUCKDESCHEL MANNO, LTD. DBA

Table of content: (NPI 1922008523)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922008523 NPI number — RUCKDESCHEL MANNO, LTD. DBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RUCKDESCHEL MANNO, LTD. DBA
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:
Provider Other Organization Name Type Code:
6
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:
1922008523
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/16/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 98809
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:
89193-8809
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-822-5433
Provider Business Mailing Address Fax Number:
702-944-0471

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
ONE BREAKTHROUGH WAY
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:
89135-3011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-822-5433
Provider Business Practice Location Address Fax Number:
702-944-0471
Provider Enumeration Date:
07/26/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MANNO
Authorized Official First Name:
PHILLIP
Authorized Official Middle Name:
Authorized Official Title or Position:
INTERIM DIRECTOR
Authorized Official Telephone Number:
702-822-5433

Provider Taxonomy Codes

  • Taxonomy code: 261QX0203X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QX0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100506879 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".




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