MEDICARE: JOEL VIDANA JR. DPT, OCS, MTC

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	2251X0800X	Orthopedic Physical Therapist	1420	NV

General Provider Information

NPI Number	:	1942404892
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOEL VIDANA JR. DPT, OCS, MTC

Provider Business Mailing Address
First Line	:	8153 WHITE MILL CT
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89131-1457
Country	:	US
Telephone Number	:	702-878-7678
Fax Number	:

Provider Business Practice Location Address
First Line	:	653 N TOWN CENTER DR
Second Line	:	110
City	:	LAS VEGAS
State	:	NV
Zip	:	89144-0514
Country	:	US
Telephone Number	:	702-233-7470
Fax Number	:

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

Provider Enumeration Date	:	06/13/2007
Last Update Date	:	07/08/2007

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