MEDICARE: OLEXIY KORSHUN ETC.

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	332B00000X	Durable Medical Equipment & Medical Supplies	B6443215	CA

General Provider Information

NPI Number	:	1356533814
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OLEXIY KORSHUN ETC.

Provider Business Mailing Address
First Line	:	4375 LAS VEGAS BLVD N
Second Line	:	SUITE#6
City	:	LAS VEGAS
State	:	NV
Zip	:	89115-0587
Country	:	US
Telephone Number	:	702-643-2548
Fax Number	:

Provider Business Practice Location Address
First Line	:	4375 NORTH LAS VEGAS BLVD.
Second Line	:	SUITE #6
City	:	LAS VEGAS
State	:	NV
Zip	:	89115
Country	:	US
Telephone Number	:	702-643-2548
Fax Number	:

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

Provider Enumeration Date	:	08/17/2007
Last Update Date	:	08/17/2007

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