MEDICARE: SUMMERLIN MASSAGENV, LLC

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	225700000X	Massage Therapist	NVMT 4434	NV

General Provider Information

NPI Number	:	1477850659
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUMMERLIN MASSAGENV, LLC

Provider Business Mailing Address
First Line	:	8950 W CHARLESTON BLVD STE 7
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-5475
Country	:	US
Telephone Number	:	702-212-3689
Fax Number	:

Provider Business Practice Location Address
First Line	:	8950 W CHARLESTON BLVD STE 7
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-5475
Country	:	US
Telephone Number	:	702-212-3689
Fax Number	:

Authorized Official
Title or Position	:	CLINIC ADMINISTRATOR
Name	:	MS. DALE L SANDERSON
Credential	:
Telephone Number	:	702-212-3689

Provider Enumeration Date	:	02/23/2011
Last Update Date	:	02/23/2011

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