Healthcare Provider Details

I. General information

NPI: 1912082140
Provider Name (Legal Business Name): FAMILY AND SPORTS PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 04/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7351 PRAIRIE FALCON RD STE 100
LAS VEGAS NV
89128-0820
US

IV. Provider business mailing address

7351 PRAIRIE FALCON RD STE 100
LAS VEGAS NV
89128-0820
US

V. Phone/Fax

Practice location:
  • Phone: 702-968-0520
  • Fax: 702-968-0521
Mailing address:
  • Phone: 702-968-0520
  • Fax: 702-968-0521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. JEFF DIETRICH
Title or Position: DIRECTOR, SECRETARY
Credential: PT
Phone: 702-968-0520