MEDICARE: SANDRA CATHERINE TAVISORA NCTM

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	174400000X	Specialist	NVMT3113	NV

General Provider Information

NPI Number	:	1376725648
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANDRA CATHERINE TAVISORA NCTM

Provider Business Mailing Address
First Line	:	6961 PUETOLLANO DR
Second Line	:
City	:	N LAS VEGAS
State	:	NV
Zip	:	89084-2339
Country	:	US
Telephone Number	:	480-650-2010
Fax Number	:

Provider Business Practice Location Address
First Line	:	6961 PUETOLLANO DR
Second Line	:
City	:	N LAS VEGAS
State	:	NV
Zip	:	89084-2339
Country	:	US
Telephone Number	:	480-650-2010
Fax Number	:

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

Provider Enumeration Date	:	11/28/2007
Last Update Date	:	12/19/2007

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