Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225400000X | Rehabilitation Practitioner |
NPI | 1003312307 |
---|---|
Provider Name | Theodore Luna-Stupec |
First Address | Las Vegas, NV 89130-3180 |
Second Address | Las Vegas, NV 89130-3180 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/04/2018 |
Last Update Date | 04/04/2018 |