Provider Demographics
NPI:1679823975
Name:MERCADO, CONSTANTINO
Entity Type:Individual
Prefix:
First Name:CONSTANTINO
Middle Name:
Last Name:MERCADO
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 1:5536 SPICEBERRY DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89135-4043
Mailing Address - Country:US
Mailing Address - Phone:770-364-5668
Mailing Address - Fax:
Practice Address - Street 1:5536 SPICEBERRY DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89135-4043
Practice Address - Country:US
Practice Address - Phone:770-364-5668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-13
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner