Provider Demographics
NPI:1013559533
Name:MEDINA, ROBERTO JOSE (DC)
Entity Type:Individual
Prefix:
First Name:ROBERTO
Middle Name:JOSE
Last Name:MEDINA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8678 SPRING MOUNTAIN RD STE 110
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-4103
Mailing Address - Country:US
Mailing Address - Phone:702-644-3333
Mailing Address - Fax:702-644-3336
Practice Address - Street 1:8678 SPRING MOUNTAIN RD STE 110
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-4103
Practice Address - Country:US
Practice Address - Phone:702-644-3333
Practice Address - Fax:702-644-3336
Is Sole Proprietor?:No
Enumeration Date:2019-10-16
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVB01794111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVB01794OtherCHIROPRACTIC PHYSICIANS BOARD OF NEVADA