Provider Demographics
NPI:1487929865
Name:BANKS, SEDARRYL LAMONT
Entity type:Individual
Prefix:
First Name:SEDARRYL
Middle Name:LAMONT
Last Name:BANKS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 WYATT AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-2746
Mailing Address - Country:US
Mailing Address - Phone:775-276-4796
Mailing Address - Fax:
Practice Address - Street 1:2820 S JONES BLVD STE 1
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-5650
Practice Address - Country:US
Practice Address - Phone:702-556-1511
Practice Address - Fax:702-888-0035
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-18
Last Update Date:2012-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner