Provider Demographics
NPI:1205197753
Name:LEBLANC, EMMETT
Entity Type:Individual
Prefix:
First Name:EMMETT
Middle Name:
Last Name:LEBLANC
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 1:4107 W CHEYENNE AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89032-3476
Mailing Address - Country:US
Mailing Address - Phone:702-636-9400
Mailing Address - Fax:
Practice Address - Street 1:4107 W CHEYENNE AVE STE 100
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-3476
Practice Address - Country:US
Practice Address - Phone:702-636-9400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-31
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV225400000XMedicaid