Provider Demographics
NPI:1346029683
Name:WILANSKY, BORUCH
Entity Type:Individual
Prefix:
First Name:BORUCH
Middle Name:
Last Name:WILANSKY
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 1:8437 SQUAW VALLEY AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-7619
Mailing Address - Country:US
Mailing Address - Phone:929-391-0668
Mailing Address - Fax:
Practice Address - Street 1:9100 W DESERT INN RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-6323
Practice Address - Country:US
Practice Address - Phone:702-472-8505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-26
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVOT-3327225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist