Basic Information
Provider Information
NPI: 1033556642
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: SHRECENGOST
FirstName: CORY
MiddleName: ADAM
NamePrefix:  
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Credential:  
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Mailing Information
Address1: 4160 S PECOS RD STE 17
Address2:  
City: LAS VEGAS
State: NV
PostalCode: 891215027
CountryCode: US
TelephoneNumber: 7023963464
FaxNumber:  
Practice Location
Address1: 4160 S PECOS RD STE 17
Address2:  
City: LAS VEGAS
State: NV
PostalCode: 891215027
CountryCode: US
TelephoneNumber: 7023963464
FaxNumber:  
Other Information
ProviderEnumerationDate: 05/23/2013
LastUpdateDate: 05/23/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
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IsSoleProprietor: Y
IsOrganizationSubpart:  
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AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225400000X  Y Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner 

No ID Information.


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