Healthcare Provider Details

I. General information

NPI: 1497390850
Provider Name (Legal Business Name): RAYMOND JOHN MELLINGER PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2019
Last Update Date: 07/13/2022
Certification Date: 07/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7250 PEAK DRIVE SUITE 118
LAS VEGAS NV
89128
US

IV. Provider business mailing address

7250 PEAK DRIVE SUITE 118
LAS VEGAS NV
89128
US

V. Phone/Fax

Practice location:
  • Phone: 702-893-3333
  • Fax: 702-839-0095
Mailing address:
  • Phone: 702-893-3333
  • Fax: 702-839-0095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number4143
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number4143
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: