Healthcare Provider Details

I. General information

NPI: 1992057426
Provider Name (Legal Business Name): KUMMIRE EDWARDS SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2012
Last Update Date: 11/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 N RAINBOW BLVD SUITE 110
LAS VEGAS NV
89107-1189
US

IV. Provider business mailing address

800 N RAINBOW BLVD SUITE 110
LAS VEGAS NV
89107-1189
US

V. Phone/Fax

Practice location:
  • Phone: 702-778-8922
  • Fax: 702-778-8789
Mailing address:
  • Phone: 702-778-8922
  • Fax: 702-778-8789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: