Provider Demographics
NPI:1477815793
Name:FUNCHES, SHONTARIUS A
Entity Type:Individual
Prefix:MR
First Name:SHONTARIUS
Middle Name:A
Last Name:FUNCHES
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 1:800 N RAINBOW BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89107-1189
Mailing Address - Country:US
Mailing Address - Phone:702-778-8922
Mailing Address - Fax:
Practice Address - Street 1:800 N RAINBOW BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89107-1189
Practice Address - Country:US
Practice Address - Phone:702-778-8922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-12
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1639470172Medicaid