Provider Demographics
NPI:1174292668
Name:ENGRAM, EUGENE III
Entity Type:Individual
Prefix:
First Name:EUGENE
Middle Name:
Last Name:ENGRAM
Suffix:III
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 1:7339 CROW CANYON AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89179-1246
Mailing Address - Country:US
Mailing Address - Phone:323-365-5544
Mailing Address - Fax:
Practice Address - Street 1:2220 ALISE ST
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030-4061
Practice Address - Country:US
Practice Address - Phone:323-365-5544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-08
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician