Provider Demographics
NPI:1629217310
Name:PETER, ENOBONG
Entity Type:Individual
Prefix:
First Name:ENOBONG
Middle Name:
Last Name:PETER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 S JONES BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-6787
Mailing Address - Country:US
Mailing Address - Phone:702-358-7308
Mailing Address - Fax:
Practice Address - Street 1:3300 S JONES BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-6787
Practice Address - Country:US
Practice Address - Phone:702-452-0808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-19
Last Update Date:2009-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies