Provider Demographics
NPI:1205494523
Name:BERNAL BLANCO, JORGE LUIS
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:LUIS
Last Name:BERNAL BLANCO
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 1:1025 SIERRA VISTA DR APT 33
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89169-2939
Mailing Address - Country:US
Mailing Address - Phone:702-762-6326
Mailing Address - Fax:
Practice Address - Street 1:1025 SIERRA VISTA DR APT 33
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89169-2939
Practice Address - Country:US
Practice Address - Phone:702-762-6326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-01
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV3747P1801XMedicaid