MEDICARE: JON G REQUENA

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	:	1992015507
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JON G REQUENA

Provider Business Mailing Address
First Line	:	8916 CRYSTAL CORAL WAY
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89123-3141
Country	:	US
Telephone Number	:	702-782-8557
Fax Number	:

Provider Business Practice Location Address
First Line	:	8916 CRYSTAL CORAL WAY
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89123-3141
Country	:	US
Telephone Number	:	702-782-8557
Fax Number	:

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

Provider Enumeration Date	:	10/15/2010
Last Update Date	:	10/15/2010

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Directions to “ JON G REQUENA ” Practice Location

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