Provider Demographics
NPI:1699870337
Name:ORTEGA, GUADALUPE
Entity type:Individual
Prefix:
First Name:GUADALUPE
Middle Name:
Last Name:ORTEGA
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 1:4912 PEARL MOUNTAIN CT
Mailing Address - Street 2:
Mailing Address - City:N LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89031-0390
Mailing Address - Country:US
Mailing Address - Phone:702-646-4033
Mailing Address - Fax:
Practice Address - Street 1:630 S RANCHO DR
Practice Address - Street 2:STE D
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4873
Practice Address - Country:US
Practice Address - Phone:702-878-2244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1158OtherLICENSE #