=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962661413
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GOOD SHEPHERD REHABILITATION INSTITUTE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2008
-----------------------------------------------------
Last Update Date | 06/09/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4275 BURNHAM AVE STE 255
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89119-5488
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-380-1060
-----------------------------------------------------
Fax | 702-380-1081
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4275 BURNHAM AVE STE 255
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89119-5488
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-380-1060
-----------------------------------------------------
Fax | 702-380-1081
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PT
-----------------------------------------------------
Name | MYRA JUNE LUY SERRANO
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 702-380-1060
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 2073
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------