=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013890664
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAS VEGAS MOBILE RESOURCE HUB
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2025
-----------------------------------------------------
Last Update Date | 07/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 732 S 6TH ST STE R
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89101-6948
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-239-8520
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7200 PIRATES COVE RD UNIT 1078
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89145-4259
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 725-246-6247
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | BANDY MCCULLOUCH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 775-239-8520
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225400000X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------