Basic Information
| Provider Information | |||||||||
| NPI: | 1801118351 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | REHAB & INDUSTRIAL SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | REHAB SERVICES OF NEVADA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 325 HANSON ST | ||||||||
| Address2: | |||||||||
| City: | WINNEMUCCA | ||||||||
| State: | NV | ||||||||
| PostalCode: | 894453607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7757482086 | ||||||||
| FaxNumber: | 7757482087 | ||||||||
| Practice Location | |||||||||
| Address1: | 925 NORTH WELLS AVENUE | ||||||||
| Address2: | UNIT B | ||||||||
| City: | WEST WENDOVER | ||||||||
| State: | NV | ||||||||
| PostalCode: | 89883 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7756644144 | ||||||||
| FaxNumber: | 7756644141 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2010 | ||||||||
| LastUpdateDate: | 02/25/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TUCKER | ||||||||
| AuthorizedOfficialFirstName: | DANA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE CREDENTIALER | ||||||||
| AuthorizedOfficialTelephone: | 7757482086 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 305R00000X | Y | Managed Care Organizations | Preferred Provider Organization |
ID Information
| ID | Type | State | Issuer | Description | 100502503 | 05 | NV | MEDICAID |