MEDICARE: SHADOW CREEK LLC

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	1402	NV
2	225X00000X	Occupational Therapist	12-0188	NV

General Provider Information

NPI Number	:	1871946558
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHADOW CREEK LLC

Provider Business Mailing Address
First Line	:	2804 SHADOW CREEK CIR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-2437
Country	:	US
Telephone Number	:	801-380-9724
Fax Number	:

Provider Business Practice Location Address
First Line	:	2804 SHADOW CREEK CIR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-2437
Country	:	US
Telephone Number	:	801-380-9724
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	EMILY DAVIS
Credential	:	OTR/L
Telephone Number	:	801-380-9724

Provider Enumeration Date	:	07/19/2016
Last Update Date	:	07/19/2016

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Directions to “SHADOW CREEK LLC ” Practice Location

Language	Start Address	Practice Location

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