Basic Information
Provider Information | |||||||||
NPI: | 1821398280 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GALVEZ | ||||||||
FirstName: | AGNES | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MISS | ||||||||
NameSuffix: |   | ||||||||
Credential: | MS, RD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3333 E CAMELBACK RD | ||||||||
Address2: | STE 180 | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850182396 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6029970484 | ||||||||
FaxNumber: | 6022243315 | ||||||||
Practice Location | |||||||||
Address1: | 2545 S BRUCE ST STE 200 | ||||||||
Address2: |   | ||||||||
City: | LAS VEGAS | ||||||||
State: | NV | ||||||||
PostalCode: | 891691778 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7027322438 | ||||||||
FaxNumber: | 7027337876 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/01/2010 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X |   |   | N |   | Dietary & Nutritional Service Providers | Dietitian, Registered |   | 133VN1005X | 32884DI-2 | NV | Y |   | Dietary & Nutritional Service Providers | Dietitian, Registered | Nutrition, Renal |
ID Information
ID | Type | State | Issuer | Description | 1821398280 | 05 | NV |   | MEDICAID |