MEDICARE: JACQUELYN ELISALDE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225400000X	Rehabilitation Practitioner	193450A	NV

General Provider Information

NPI Number	:	1023367869
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELYN ELISALDE

Provider Business Mailing Address
First Line	:	705 STORMCREST LN.
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89107-4369
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3620 N. RANCHO DR. SUITE 113
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89130-9998
Country	:	US
Telephone Number	:	702-362-5181
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/07/2012
Last Update Date	:	10/04/2012

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