=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376997940
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARC MAGSTADT PT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2016
-----------------------------------------------------
Last Update Date | 04/19/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2175 GREEN VISTA DR STE 210
-----------------------------------------------------
City | SPARKS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89431-8510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-674-8903
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3784 KEPLER DR
-----------------------------------------------------
City | SPARKS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89436-7184
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-250-4934
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 2662
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------