Provider Demographics
NPI:1023612066
Name:FUNCTIONAL NEURO REHAB, LLC
Entity type:Organization
Organization Name:FUNCTIONAL NEURO REHAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:MARIAH
Authorized Official - Last Name:OLIVERO-CHEW
Authorized Official - Suffix:
Authorized Official - Credentials:OT
Authorized Official - Phone:575-479-7056
Mailing Address - Street 1:304 S JONES BLVD STE 3511
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89107-2623
Mailing Address - Country:US
Mailing Address - Phone:575-479-7056
Mailing Address - Fax:
Practice Address - Street 1:650 WHITNEY RANCH DR APT 1511
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89014-2615
Practice Address - Country:US
Practice Address - Phone:253-261-8436
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-30
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation