MEDICARE: NIC SPARROW

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	225100000X	Physical Therapist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1257	OTHER	NV	LICENSE #

General Provider Information

NPI Number	:	1629186945
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NIC SPARROW

Provider Business Mailing Address
First Line	:	1601 S RAINBOW BLVD STE 160
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-0029
Country	:	US
Telephone Number	:	702-916-2777
Fax Number	:	702-916-2778

Provider Business Practice Location Address
First Line	:	5785 CENTENNIAL CENTER BLVD STE 220
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89149-7111
Country	:	US
Telephone Number	:	702-916-2777
Fax Number	:	702-916-2778

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

Provider Enumeration Date	:	08/27/2006
Last Update Date	:	02/09/2024

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Directions to “ NIC SPARROW ” Practice Location

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