Healthcare Provider Details

I. General information

NPI: 1770396103
Provider Name (Legal Business Name): STEPHEN MCCAIN CNC, CPT, OLY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2025
Last Update Date: 01/29/2025
Certification Date: 01/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8744 MESA CANOGO DR
LAS VEGAS NV
89148-1433
US

IV. Provider business mailing address

8744 MESA CANOGO DR
LAS VEGAS NV
89148-1433
US

V. Phone/Fax

Practice location:
  • Phone: 310-717-8686
  • Fax:
Mailing address:
  • Phone: 310-717-8686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224Y00000X
TaxonomyClinical Exercise Physiologist
License Number1200502608
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number1190351195
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: