Provider Demographics
NPI:1942404892
Name:VIDANA, JOEL JR (DPT, OCS, MTC)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:
Last Name:VIDANA
Suffix:JR
Gender:M
Credentials:DPT, OCS, MTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8153 WHITE MILL CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89131-1457
Mailing Address - Country:US
Mailing Address - Phone:702-878-7678
Mailing Address - Fax:
Practice Address - Street 1:653 N TOWN CENTER DR
Practice Address - Street 2:110
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89144-0514
Practice Address - Country:US
Practice Address - Phone:702-233-7470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV14202251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic