MEDICARE: MRS. MARIE ROSELLE DESEO

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	261QR0401X	Comprehensive Outpatient Rehabilitation Facility (CORF)	294504	NV

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	294504	OTHER	NV	MEDICARE ID-TYPE

General Provider Information

NPI Number	:	1326426362
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARIE ROSELLE DESEO

Provider Business Mailing Address
First Line	:	7375 PRAIRIE FALCON RD STE 120
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-0810
Country	:	US
Telephone Number	:	702-869-4401
Fax Number	:	702-869-9904

Provider Business Practice Location Address
First Line	:	7375 PRAIRIE FALCON RD STE 120
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-0810
Country	:	US
Telephone Number	:	702-869-4401
Fax Number	:	702-869-9904

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

Provider Enumeration Date	:	05/11/2015
Last Update Date	:	05/12/2015

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