Provider Demographics
NPI:1902639917
Name:GOPENGMD PROF LLC
Entity type:Organization
Organization Name:GOPENGMD PROF LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS ADMINSTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:UGANIZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-703-1668
Mailing Address - Street 1:8440 W LAKE MEAD BLVD STE 111
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-7648
Mailing Address - Country:US
Mailing Address - Phone:888-845-7672
Mailing Address - Fax:
Practice Address - Street 1:8440 W LAKE MEAD BLVD STE 111
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-7648
Practice Address - Country:US
Practice Address - Phone:888-845-7672
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-23
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty