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General NPI Number Information
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NPI Number | 1407465057
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Entity Type | Individual
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Provider Name | KRISTIN DIFUNTORUM OD
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Gender | Female
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Dates
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Enumeration Date | 07/29/2020
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Last Update Date | 11/17/2020
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Provider Practice Location Address
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Address Line | 230 N NELLIS BLVD STE B
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City | LAS VEGAS
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State | NV
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Zip | 89110-6003
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Country | US
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Telephone | 702-360-8070
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Fax |
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Provider Business Mailing Address
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Address Line | 333 SANTA FE ST
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City | LAS VEGAS
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State | NV
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Zip | 89145-5327
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 1072
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License Number State | NV
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