Provider Demographics
NPI:1003294331
Name:RISCO, BERNARD TAVONE
Entity Type:Individual
Prefix:MR
First Name:BERNARD
Middle Name:TAVONE
Last Name:RISCO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 INDIAN RIVER DR
Mailing Address - Street 2:BUILDING 244 APT. 481
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-5294
Mailing Address - Country:US
Mailing Address - Phone:215-796-7901
Mailing Address - Fax:
Practice Address - Street 1:5000 INDIAN RIVER DR
Practice Address - Street 2:BUILDING 244 APT. 481
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-5294
Practice Address - Country:US
Practice Address - Phone:215-796-7901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-06
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health