1497734503 NPI number — REBECCA L PRIVITT PT

Table of content: REBECCA L PRIVITT PT (NPI 1497734503)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497734503 NPI number — REBECCA L PRIVITT PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRIVITT
Provider First Name:
REBECCA
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PUCKETT
Provider Other First Name:
REBECCA
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1497734503
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8561 W FISHER AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89149-4057
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-545-0265
Provider Business Mailing Address Fax Number:
928-771-9519

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4765 S DURANGO DR
Provider Second Line Business Practice Location Address:
SUITE #106
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89147-8145
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-898-7633
Provider Business Practice Location Address Fax Number:
927-881-9519
Provider Enumeration Date:
01/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  2039 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 783292 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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