Healthcare Provider Details

I. General information

NPI: 1104745942
Provider Name (Legal Business Name): DANIEL LANE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2026
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6671 LAS VEGAS BLVD S UNIT 210 OFFICE 247
LAS VEGAS NV
89119-3289
US

IV. Provider business mailing address

6671 LAS VEGAS BLVD S UNIT 210 OFFICE 247
LAS VEGAS NV
89119-3289
US

V. Phone/Fax

Practice location:
  • Phone: 718-215-5311
  • Fax: 718-865-5165
Mailing address:
  • Phone: 718-215-5311
  • Fax: 718-865-5165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberBACB1557840
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: