Provider Demographics
NPI:1780151415
Name:GERONA PORCEL LLC
Entity type:Organization
Organization Name:GERONA PORCEL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:BERNAL PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-272-8619
Mailing Address - Street 1:1912 MAGNOLIA DR
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89014-5192
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2110 E FLAMINGO RD STE 205
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-5192
Practice Address - Country:US
Practice Address - Phone:702-620-5105
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-31
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty