Provider Demographics
NPI:1235289653
Name:DES-REHAB INC
Entity Type:Organization
Organization Name:DES-REHAB INC
Other - Org Name:DESERT REHABILITATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-893-0800
Mailing Address - Street 1:3201 S MARYLAND PKWY
Mailing Address - Street 2:SUITE 218
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89109-2441
Mailing Address - Country:US
Mailing Address - Phone:702-893-0800
Mailing Address - Fax:702-893-0109
Practice Address - Street 1:3201 S MARYLAND PKWY
Practice Address - Street 2:SUITE 218
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109-2441
Practice Address - Country:US
Practice Address - Phone:702-893-0800
Practice Address - Fax:702-893-0109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV6244207R00000X
NV5908208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVVWCHDVMedicare PIN