Individual
MR. JACK GARY GOLLA
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
QBA
Contact information
Practice address
670 WASHOE DR, CARSON CITY, NV 89704-9528
(775) 849-3165
(775) 849-9425
Mailing address
670 WASHOE DR, CARSON CITY, NV 89704-9528
(775) 849-3165
(775) 849-9425
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
Primary
FF467210
NV
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
9005043219
—
NV
Enumeration date
11/08/2010
Last updated
11/08/2010
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