Provider Demographics
NPI:1912541665
Name:OTOMURO, JORGE
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:OTOMURO
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 1:211 LYNBROOK ST
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89012-4884
Mailing Address - Country:US
Mailing Address - Phone:702-339-8718
Mailing Address - Fax:
Practice Address - Street 1:2770 S MARYLAND PKWY STE 108B-G
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109-1554
Practice Address - Country:US
Practice Address - Phone:702-463-7779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-05
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant