MEDICARE: INDIGO-BANE 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	235Z00000X	Speech-Language Pathologist

General Provider Information

NPI Number	:	1689421976
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDIGO-BANE LLC

Provider Business Mailing Address
First Line	:	330 E WARM SPRINGS RD STE 122
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-4281
Country	:	US
Telephone Number	:	725-255-5321
Fax Number	:	725-255-5323

Provider Business Practice Location Address
First Line	:	330 E WARM SPRINGS RD STE 122
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-4281
Country	:	US
Telephone Number	:	725-255-5321
Fax Number	:	725-255-5323

Authorized Official
Title or Position	:	MANAGER
Name	:	MICHAEL LOPEZ
Credential	:
Telephone Number	:	725-255-5321

Provider Enumeration Date	:	05/03/2024
Last Update Date	:	05/03/2024

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Directions to “INDIGO-BANE LLC ” Practice Location

Language	Start Address	Practice Location

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