MEDICARE: DEANDRE LAMONT SUMMLIN

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	225400000X	Rehabilitation Practitioner

General Provider Information

NPI Number	:	1699011247
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEANDRE LAMONT SUMMLIN

Provider Business Mailing Address
First Line	:	1525 PINTO LN
Second Line	:	APT 39
City	:	LAS VEGAS
State	:	NV
Zip	:	89106-4104
Country	:	US
Telephone Number	:	702-981-0701
Fax Number	:

Provider Business Practice Location Address
First Line	:	1525 PINTO LN
Second Line	:	APT 39
City	:	LAS VEGAS
State	:	NV
Zip	:	89106-4104
Country	:	US
Telephone Number	:	702-981-0701
Fax Number	:

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

Provider Enumeration Date	:	12/28/2012
Last Update Date	:	04/10/2013

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Directions to “ DEANDRE LAMONT SUMMLIN ” Practice Location

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