Provider Demographics
NPI:1821515735
Name:GREATHOUSE PHYSICAL THERAPY SPORTS SCIENCE TRAINING, LLC
Entity Type:Organization
Organization Name:GREATHOUSE PHYSICAL THERAPY SPORTS SCIENCE TRAINING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:GREATHOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:702-580-4184
Mailing Address - Street 1:1845 VILLAGE CENTER CIR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89134
Mailing Address - Country:US
Mailing Address - Phone:702-723-9006
Mailing Address - Fax:
Practice Address - Street 1:1845 VILLAGE CENTER CIR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89134
Practice Address - Country:US
Practice Address - Phone:702-580-4184
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-23
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV20161709598261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1205167517Medicaid