Provider Demographics
NPI:1841528882
Name:THURMOND, DWAYNE (LMT,MCTMB,NCMA,CMCP)
Entity type:Individual
Prefix:
First Name:DWAYNE
Middle Name:
Last Name:THURMOND
Suffix:
Gender:M
Credentials:LMT,MCTMB,NCMA,CMCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9353 W TWAIN AVE
Mailing Address - Street 2:APT. 185
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89147-6861
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 S RAINBOW BLVD
Practice Address - Street 2:STE. 21
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89145-5362
Practice Address - Country:US
Practice Address - Phone:702-880-4325
Practice Address - Fax:702-870-2889
Is Sole Proprietor?:No
Enumeration Date:2009-12-03
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNVMT.3065225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist