MEDICARE: JACK D. CLOSE AND ASSOCIATES

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	225100000X	Physical Therapist	57	NV

General Provider Information

NPI Number	:	1700992971
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACK D. CLOSE AND ASSOCIATES

Provider Business Mailing Address
First Line	:	3650 S EASTERN AVE
Second Line	:	#100
City	:	LAS VEGAS
State	:	NV
Zip	:	89109-3379
Country	:	US
Telephone Number	:	702-731-6873
Fax Number	:	702-731-2565

Provider Business Practice Location Address
First Line	:	7373 PEAK DR
Second Line	:	#230
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-9003
Country	:	US
Telephone Number	:	702-215-4353
Fax Number	:	702-215-4356

Authorized Official
Title or Position	:	PHYSICAL THERAPIST
Name	:	MR. JACK DEAN CLOSE SR.
Credential	:	M.A.P.T,FAPTA
Telephone Number	:	702-731-6873

Provider Enumeration Date	:	08/21/2006
Last Update Date	:	05/23/2012

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