Provider Demographics
NPI:1194317503
Name:MONDRAGON, JAMES
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:MONDRAGON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3005 GARDENDALE ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-2620
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1516 E TROPICANA AVE STE 199
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-8323
Practice Address - Country:US
Practice Address - Phone:725-214-7776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-07
Last Update Date:2021-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider