Provider Demographics
NPI:1083252308
Name:PRVULOV, NEBOJSA (BSC,LMT,MMT,CNC,HT)
Entity Type:Individual
Prefix:MR
First Name:NEBOJSA
Middle Name:
Last Name:PRVULOV
Suffix:
Gender:M
Credentials:BSC,LMT,MMT,CNC,HT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5105 DEL REY AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-1407
Mailing Address - Country:US
Mailing Address - Phone:702-499-0124
Mailing Address - Fax:
Practice Address - Street 1:5105 DEL REY AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-1407
Practice Address - Country:US
Practice Address - Phone:702-499-0124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-17
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNVMT.9490225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist