MEDICARE: KENNY BALLAN CRT

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	227800000X	Certified Respiratory Therapist	RC2328	NV

General Provider Information

NPI Number	:	1093138778
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNY BALLAN CRT

Provider Business Mailing Address
First Line	:	6779 PHILHARMONIC AVE
Second Line	:	A
City	:	LAS VEGAS
State	:	NV
Zip	:	89139-6784
Country	:	US
Telephone Number	:	808-398-9060
Fax Number	:

Provider Business Practice Location Address
First Line	:	6779 PHILHARMONIC AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89139-6784
Country	:	US
Telephone Number	:	808-398-9060
Fax Number	:

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

Provider Enumeration Date	:	01/30/2014
Last Update Date	:	01/30/2014

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