1497390850 NPI number — DR. RAYMOND JOHN MELLINGER PT, DPT

Table of content: DR. RAYMOND JOHN MELLINGER PT, DPT (NPI 1497390850)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497390850 NPI number — DR. RAYMOND JOHN MELLINGER PT, DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MELLINGER
Provider First Name:
RAYMOND
Provider Middle Name:
JOHN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497390850
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/13/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7250 PEAK DRIVE
Provider Second Line Business Mailing Address:
SUITE 118
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89128
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-893-3333
Provider Business Mailing Address Fax Number:
702-839-0095

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7250 PEAK DRIVE
Provider Second Line Business Practice Location Address:
SUITE 118
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89128
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-893-3333
Provider Business Practice Location Address Fax Number:
702-839-0095
Provider Enumeration Date:
11/08/2019

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: 2251S0007X , with the licence number:  4143 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2251X0800X , with the licence number: 4143 , 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)





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