Provider Demographics
NPI:1750498879
Name:MOUNTAIN LAND REHABILITATION OF NEVADA LC
Entity Type:Organization
Organization Name:MOUNTAIN LAND REHABILITATION OF NEVADA LC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:801-942-3311
Mailing Address - Street 1:PO BOX 711185
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84171-1185
Mailing Address - Country:US
Mailing Address - Phone:801-942-3311
Mailing Address - Fax:801-942-5955
Practice Address - Street 1:9484 W LAKE MEAD BLVD
Practice Address - Street 2:SUITE 8-10
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89134
Practice Address - Country:US
Practice Address - Phone:702-243-7744
Practice Address - Fax:702-243-9688
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOUNTAIN LAND REHABILITATION INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-24
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV100301Medicare PIN