Provider Demographics
NPI:1750959094
Name:DIETZ, KANDALL CHEY
Entity type:Individual
Prefix:
First Name:KANDALL
Middle Name:CHEY
Last Name:DIETZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3909 GULLIVER ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89115-0379
Mailing Address - Country:US
Mailing Address - Phone:702-427-4746
Mailing Address - Fax:
Practice Address - Street 1:1500 E TROPICANA AVE STE 163
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-6516
Practice Address - Country:US
Practice Address - Phone:702-427-4746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-14
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner