MEDICARE: EXTREMITY RECONSTRUCTIVE LLC

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	213ES0103X	Foot & Ankle Surgery Podiatrist	9205	NV

General Provider Information

NPI Number	:	1285019646
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXTREMITY RECONSTRUCTIVE LLC

Provider Business Mailing Address
First Line	:	1703 CIVIC CENTER DR
Second Line	:	SUITE #3
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89030-7212
Country	:	US
Telephone Number	:	702-388-1006
Fax Number	:	702-388-1751

Provider Business Practice Location Address
First Line	:	1703 CIVIC CENTER DR
Second Line	:	SUITE #3
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89030-7212
Country	:	US
Telephone Number	:	702-388-1006
Fax Number	:	702-388-1751

Authorized Official
Title or Position	:	OWNER
Name	:	DR. IRA WEINER
Credential	:	DPM
Telephone Number	:	702-388-1006

Provider Enumeration Date	:	07/28/2015
Last Update Date	:	07/28/2015

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Directions to “EXTREMITY RECONSTRUCTIVE LLC ” Practice Location

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