=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154808210
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DEBIPARSHAD PROFESSIONAL SERVICES PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2018
-----------------------------------------------------
Last Update Date | 07/22/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 870 SEVEN HILLS DR STE 103
-----------------------------------------------------
City | HENDERSON
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89052-4378
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-678-4658
-----------------------------------------------------
Fax | 469-453-3374
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 870 SEVEN HILLS DR STE 103
-----------------------------------------------------
City | HENDERSON
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89052-4378
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-678-4658
-----------------------------------------------------
Fax | 469-453-3374
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE MEMBER
-----------------------------------------------------
Name | KEVIN P DEBIPARSHAD
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 561-693-8792
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 204R00000X
-----------------------------------------------------
Taxonomy Name | Electrodiagnostic Medicine Physician
-----------------------------------------------------
License Number | 15997
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------