MEDICARE: MR. TED R VIDAL II PTA, LMT

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	225200000X	Physical Therapy Assistant	53320	CA
2	225700000X	Massage Therapist	NVMT.5574	NV
3	225200000X	Physical Therapy Assistant	A-1516	NV

General Provider Information

NPI Number	:	1740998434
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TED R VIDAL II PTA, LMT

Provider Business Mailing Address
First Line	:	6823 PONDEROSA WAY
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89118-2100
Country	:	US
Telephone Number	:	702-665-4054
Fax Number	:

Provider Business Practice Location Address
First Line	:	2350 IONE RD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89183-7943
Country	:	US
Telephone Number	:	702-790-3000
Fax Number	:

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

Provider Enumeration Date	:	11/10/2022
Last Update Date	:	01/09/2025

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