Provider Demographics
NPI:1992343578
Name:DESLATE, CARLO PACADA (ATC)
Entity type:Individual
Prefix:MR
First Name:CARLO
Middle Name:PACADA
Last Name:DESLATE
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1186 RED MARGIN CT UNIT 103
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89183-4975
Mailing Address - Country:US
Mailing Address - Phone:510-284-7074
Mailing Address - Fax:
Practice Address - Street 1:4980 W SAHARA AVE STE 260
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-3435
Practice Address - Country:US
Practice Address - Phone:702-820-5070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-14
Last Update Date:2019-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV05063212255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty