Provider Demographics
NPI:1558397059
Name:SPORTS MEDICINE REHABILITATION
Entity Type:Organization
Organization Name:SPORTS MEDICINE REHABILITATION
Other - Org Name:FAMILY WELLNESS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CASIANO
Authorized Official - Middle Name:R
Authorized Official - Last Name:FLAVIANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-837-4397
Mailing Address - Street 1:10001 S EASTERN AVE
Mailing Address - Street 2:210
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-3907
Mailing Address - Country:US
Mailing Address - Phone:702-837-4397
Mailing Address - Fax:702-837-7426
Practice Address - Street 1:10001 S EASTERN AVE
Practice Address - Street 2:210
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-3907
Practice Address - Country:US
Practice Address - Phone:702-837-4397
Practice Address - Fax:702-837-7426
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV9976174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty