MEDICARE: DIANA REGALADO

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	2255A2300X	Athletic Trainer
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1366984163
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANA REGALADO

Provider Business Mailing Address
First Line	:	5030 TIOGA PASS AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89139-0122
Country	:	US
Telephone Number	:	775-450-4994
Fax Number	:

Provider Business Practice Location Address
First Line	:	5030 TIOGA PASS AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89139-0122
Country	:	US
Telephone Number	:	775-450-4994
Fax Number	:

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

Provider Enumeration Date	:	11/09/2016
Last Update Date	:	11/09/2016

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Directions to “ DIANA REGALADO ” Practice Location

Language	Start Address	Practice Location

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