Provider Demographics
NPI:1578673224
Name:BRUZZESE, DOMINIC
Entity Type:Individual
Prefix:
First Name:DOMINIC
Middle Name:
Last Name:BRUZZESE
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 1:6615 W TROPICANA AVE
Mailing Address - Street 2:STE 101
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-4782
Mailing Address - Country:US
Mailing Address - Phone:702-362-6282
Mailing Address - Fax:
Practice Address - Street 1:4955 S DURANGO DR
Practice Address - Street 2:STE 100
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89113-0152
Practice Address - Country:US
Practice Address - Phone:702-254-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVA-0371OtherLICENSE #