Provider Demographics
NPI:1760783161
Name:GENTRY, TRACY VAN
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:VAN
Last Name:GENTRY
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 1:1230 W OWENS AVE
Mailing Address - Street 2:STE 6
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-2451
Mailing Address - Country:US
Mailing Address - Phone:702-636-5373
Mailing Address - Fax:
Practice Address - Street 1:1230 W OWENS AVE
Practice Address - Street 2:STE 6
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-2451
Practice Address - Country:US
Practice Address - Phone:702-636-5373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-16
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner