Provider Demographics
NPI:1487607883
Name:MESA VIEW PHYSICAL REHABILITATION, LLC
Entity type:Organization
Organization Name:MESA VIEW PHYSICAL REHABILITATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER/DIRECTOR/MSPT
Authorized Official - Prefix:
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:L
Authorized Official - Last Name:WAKEFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:702-346-1899
Mailing Address - Street 1:PO BOX 757
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:NV
Mailing Address - Zip Code:89024-0757
Mailing Address - Country:US
Mailing Address - Phone:702-346-1899
Mailing Address - Fax:702-346-8581
Practice Address - Street 1:1301 BERTHA HOWE AVE
Practice Address - Street 2:SUITE 7
Practice Address - City:MESQUITE
Practice Address - State:NV
Practice Address - Zip Code:89027-7502
Practice Address - Country:US
Practice Address - Phone:702-346-1899
Practice Address - Fax:702-346-8581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100504540Medicaid
NVV100012Medicare ID - Type UnspecifiedSCOTT OLSEN, MPT
NVV100013Medicare ID - Type UnspecifiedROBERT GROW, MPT
NVV100011Medicare ID - Type UnspecifiedTRAVIS WAKEFIELD, MSPT
NV100504540Medicaid
NVV100009Medicare ID - Type UnspecifiedGROUP NUMBER
NVV101997Medicare ID - Type UnspecifiedJERID MATHESON, MS,OTR/L