Basic Information
| Provider Information | |||||||||
| NPI: | 1790021871 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GAINES | ||||||||
| FirstName: | WILMA | ||||||||
| MiddleName: | CARTER | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2205 SPANISH TOWN AVE | ||||||||
| Address2: | |||||||||
| City: | NORTH LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 89031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7026589563 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1701 N GREEN VALLEY PKWY STE 9A | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890745991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024071100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2012 | ||||||||
| LastUpdateDate: | 04/29/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner | 3747P1801X | Y | Nursing Service Related Providers | Technician | Personal Care Attendant |
No ID Information.