MEDICARE: MISTY BOURNE

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	:	1891117297
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISTY BOURNE

Provider Business Mailing Address
First Line	:	2475 W CHEYENNE AVE
Second Line	:	170
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89032-4327
Country	:	US
Telephone Number	:	702-619-6237
Fax Number	:	888-959-8990

Provider Business Practice Location Address
First Line	:	2475 W CHEYENNE AVE
Second Line	:	170
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89032-4327
Country	:	US
Telephone Number	:	702-619-6237
Fax Number	:	888-959-8990

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

Provider Enumeration Date	:	01/20/2014
Last Update Date	:	01/20/2014

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Directions to “ MISTY BOURNE ” Practice Location

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