MEDICARE: DUSTIN DOUGLAS

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	224ZR0403X	Driving and Community Mobility Occupational Therapy Assistant
2	172A00000X	Driver

General Provider Information

NPI Number	:	1447789888
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DUSTIN DOUGLAS

Provider Business Mailing Address
First Line	:	50 N 21ST ST APT 139
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89101-5076
Country	:	US
Telephone Number	:	702-955-0912
Fax Number	:

Provider Business Practice Location Address
First Line	:	50 N 21 ST #139
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89101
Country	:	US
Telephone Number	:	702-955-0912
Fax Number	:

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

Provider Enumeration Date	:	06/08/2017
Last Update Date	:	07/21/2022

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Directions to “ DUSTIN DOUGLAS ” Practice Location

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