Basic Information
| Provider Information | |||||||||
| NPI: | 1639551203 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COLEMAN | ||||||||
| FirstName: | GREGORY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5850 POLARIS AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891183185 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7027399957 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5850 POLARIS AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891183185 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7027399957 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2015 | ||||||||
| LastUpdateDate: | 06/19/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 3150 | NV | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.