Provider Demographics
NPI:1407033269
Name:THOR MONGIE D C LTD
Entity Type:Organization
Organization Name:THOR MONGIE D C LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRITTANY
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-258-7860
Mailing Address - Street 1:2820 W CHARLESTON BLVD
Mailing Address - Street 2:#A6
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-1942
Mailing Address - Country:US
Mailing Address - Phone:702-258-7860
Mailing Address - Fax:702-258-5487
Practice Address - Street 1:2820 W CHARLESTON BLVD
Practice Address - Street 2:#A6
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-1942
Practice Address - Country:US
Practice Address - Phone:702-258-7860
Practice Address - Fax:702-258-5487
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-23
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVB00981111NR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0200XChiropractic ProvidersChiropractorRadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV37694Medicare UPIN