Provider Demographics
NPI:1316217623
Name:ALLENBACK, GAYLE (MSOT)
Entity Type:Individual
Prefix:
First Name:GAYLE
Middle Name:
Last Name:ALLENBACK
Suffix:
Gender:F
Credentials:MSOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5405 FOUNTAIN PALM ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89130-3685
Mailing Address - Country:US
Mailing Address - Phone:702-396-5710
Mailing Address - Fax:
Practice Address - Street 1:5405 FOUNTAIN PALM ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-3685
Practice Address - Country:US
Practice Address - Phone:702-396-5710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-03
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV0465171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor