MEDICARE: DAVID QUESADA LIFE PROGRAM ABA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician	1073818118	NV

General Provider Information

NPI Number	:	1073818118
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID QUESADA LIFE PROGRAM ABA

Provider Business Mailing Address
First Line	:	8101 W FLAMINGO RD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89147-7408
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7055 WINDY ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-4030
Country	:	US
Telephone Number	:	702-000-0000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/21/2011
Last Update Date	:	08/07/2019

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