Healthcare Provider Details

I. General information

NPI: 1023612066
Provider Name (Legal Business Name): FUNCTIONAL NEURO REHAB, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2020
Last Update Date: 09/06/2023
Certification Date: 11/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 WHITNEY RANCH DR APT 1511
HENDERSON NV
89014-2615
US

IV. Provider business mailing address

304 S JONES BLVD STE 3511
LAS VEGAS NV
89107-2623
US

V. Phone/Fax

Practice location:
  • Phone: 253-261-8436
  • Fax:
Mailing address:
  • Phone: 575-479-7056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number StateNULL

VIII. Authorized Official

Name: SHANNON MARIAH OLIVERO-CHEW
Title or Position: OWNER
Credential: O.T.
Phone: 575-479-7056