Provider Demographics
NPI:1407115546
Name:LAS VEGAS OUTPATIENT REHABILITATION CORPORATION
Entity Type:Organization
Organization Name:LAS VEGAS OUTPATIENT REHABILITATION CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DELSA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAGALEA
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:702-822-5814
Mailing Address - Street 1:534 S DECATUR BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89107-3931
Mailing Address - Country:US
Mailing Address - Phone:702-822-5814
Mailing Address - Fax:702-822-5816
Practice Address - Street 1:534 S DECATUR BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89107-3931
Practice Address - Country:US
Practice Address - Phone:702-822-5814
Practice Address - Fax:702-822-5816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-10
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVTRN302247163WA2000X
NVRC6512279P1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministratorGroup - Multi-Specialty
No2279P1005XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, RegisteredPulmonary RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV294511Medicare Oscar/Certification