Provider Demographics
NPI:1285019646
Name:EXTREMITY RECONSTRUCTIVE LLC
Entity Type:Organization
Organization Name:EXTREMITY RECONSTRUCTIVE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:IRA
Authorized Official - Middle Name:
Authorized Official - Last Name:WEINER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:702-388-1006
Mailing Address - Street 1:1703 CIVIC CENTER DR
Mailing Address - Street 2:SUITE #3
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89030-7212
Mailing Address - Country:US
Mailing Address - Phone:702-388-1006
Mailing Address - Fax:702-388-1751
Practice Address - Street 1:1703 CIVIC CENTER DR
Practice Address - Street 2:SUITE #3
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030-7212
Practice Address - Country:US
Practice Address - Phone:702-388-1006
Practice Address - Fax:702-388-1751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-28
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV9205213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty