Healthcare Provider Details

I. General information

NPI: 1477698785
Provider Name (Legal Business Name): ANTHONY JOHN HOUSE A.T.C., C.S.C.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4505 MARYLAND PARKWAY
LAS VEGAS NV
89154-3034
US

IV. Provider business mailing address

3241 KEY LARGO DR APT 103
LAS VEGAS NV
89120-5306
US

V. Phone/Fax

Practice location:
  • Phone: 702-895-3419
  • Fax:
Mailing address:
  • Phone: 412-720-6478
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0506119
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: