=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013559533
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERTO JOSE MEDINA DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2019
-----------------------------------------------------
Last Update Date | 11/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8678 SPRING MOUNTAIN RD STE 110
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89117-4103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-644-3333
-----------------------------------------------------
Fax | 702-644-3336
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8678 SPRING MOUNTAIN RD STE 110
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89117-4103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-644-3333
-----------------------------------------------------
Fax | 702-644-3336
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | B01794
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------