MEDICARE: JACOB ROLAND BEVELL DPT

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	6361	NV

General Provider Information

NPI Number	:	1780440792
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB ROLAND BEVELL DPT

Provider Business Mailing Address
First Line	:	49 TIERRA BUENA DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89110-4944
Country	:	US
Telephone Number	:	702-863-9499
Fax Number	:

Provider Business Practice Location Address
First Line	:	2550 NATURE PARK DR STE 250
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89084-3206
Country	:	US
Telephone Number	:	702-863-9499
Fax Number	:

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

Provider Enumeration Date	:	02/27/2024
Last Update Date	:	02/27/2024

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