Provider Demographics
NPI:1417450610
Name:SERRALVO MALPICA, GILBERTO
Entity Type:Individual
Prefix:
First Name:GILBERTO
Middle Name:
Last Name:SERRALVO MALPICA
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 1:4694 TAMALPIAS AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-1638
Mailing Address - Country:US
Mailing Address - Phone:702-902-6068
Mailing Address - Fax:
Practice Address - Street 1:620 E TWAIN AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89169-4115
Practice Address - Country:US
Practice Address - Phone:702-437-9654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-14
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty