MEDICARE: DONALD WALLACE PERKINS

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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1588155048
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DONALD WALLACE PERKINS

Provider Business Mailing Address
First Line	:	2801 S VALLEY VIEW BLVD
Second Line	:	STE 6
City	:	LAS VEGAS
State	:	NV
Zip	:	89102-0166
Country	:	US
Telephone Number	:	210-714-9829
Fax Number	:

Provider Business Practice Location Address
First Line	:	2525 N DECATUR BLVD STE 2
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89108-2976
Country	:	US
Telephone Number	:	760-579-3870
Fax Number	:

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

Provider Enumeration Date	:	05/21/2018
Last Update Date	:	06/26/2019

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