MEDICARE: DIRECTPT, 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	225100000X	Physical Therapist		NV
2	225X00000X	Occupational Therapist		NV
3	261QP2000X	Physical Therapy Clinic/Center	NV20161319331	NV

General Provider Information

NPI Number	:	1770932527
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIRECTPT, LLC

Provider Business Mailing Address
First Line	:	8910 W TROPICANA AVE
Second Line	:	SUITE 6
City	:	LAS VEGAS
State	:	NV
Zip	:	89147-8131
Country	:	US
Telephone Number	:	844-900-9669
Fax Number	:

Provider Business Practice Location Address
First Line	:	8910 W TROPICANA AVE
Second Line	:	SUITE 6
City	:	LAS VEGAS
State	:	NV
Zip	:	89147-8131
Country	:	US
Telephone Number	:	844-900-9669
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	HARRISON DIEP
Credential	:	DPT
Telephone Number	:	844-900-9669

Provider Enumeration Date	:	06/11/2016
Last Update Date	:	10/12/2016

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