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General NPI Number Information
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NPI Number | 1255503736
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Entity Type | Organization
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Legal Business Name | LAS VEGAS BODYWORKS LLC
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Dates
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Enumeration Date | 03/25/2008
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Last Update Date | 06/05/2013
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Provider Practice Location Address
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Address Line | 508 UNIVERSITY AVE
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City | LAS VEGAS
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State | NM
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Zip | 87701-4349
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Country | US
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Telephone | 505-454-0443
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Fax | 505-454-0498
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Provider Business Mailing Address
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Address Line | 508 UNIVERSITY AVE
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City | LAS VEGAS
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State | NM
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Zip | 87701-4349
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Country | US
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Telephone | 505-454-0443
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Fax | 505-454-0498
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Authorized Official
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Title or Position | PHYSICAL THERAPIST
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Name | MR. RANDY MASAO NAKASONE
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Credential | PT
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Telephone | 505-454-0443
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 1308
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License Number State | NM
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