Provider Demographics
NPI:1659669687
Name:FULLER, LASCHAVIO (EDD)
Entity type:Individual
Prefix:DR
First Name:LASCHAVIO
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:770 W LONE MOUNTAIN RD
Mailing Address - Street 2:2077
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89031-3008
Mailing Address - Country:US
Mailing Address - Phone:702-540-0344
Mailing Address - Fax:702-331-0785
Practice Address - Street 1:770 W LONE MOUNTAIN RD
Practice Address - Street 2:2077
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89031-3008
Practice Address - Country:US
Practice Address - Phone:702-540-0344
Practice Address - Fax:702-331-0785
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-12
Last Update Date:2011-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner