MEDICARE: MRS. KEISHA EVANS

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	225400000X	Rehabilitation Practitioner

General Provider Information

NPI Number	:	1104119577
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KEISHA EVANS

Provider Business Mailing Address
First Line	:	2780 S JONES BLVD STE F2-145
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-5628
Country	:	US
Telephone Number	:	702-362-7300
Fax Number	:	702-893-4662

Provider Business Practice Location Address
First Line	:	2780 S JONES BLVD STE F2-145
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-5628
Country	:	US
Telephone Number	:	702-362-7300
Fax Number	:	702-893-4662

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

Provider Enumeration Date	:	05/18/2011
Last Update Date	:	05/18/2011

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