Healthcare Provider Details

I. General information

NPI: 1447789888
Provider Name (Legal Business Name): DUSTIN DOUGLAS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 N 21 ST #139
LAS VEGAS NV
89101
US

IV. Provider business mailing address

50 N 21ST ST APT 139
LAS VEGAS NV
89101-5076
US

V. Phone/Fax

Practice location:
  • Phone: 702-955-0912
  • Fax:
Mailing address:
  • Phone: 702-955-0912
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224ZR0403X
TaxonomyDriving and Community Mobility Occupational Therapy Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: