Provider Demographics
NPI:1902149925
Name:WARE, THEODORE ALLEN
Entity Type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:ALLEN
Last Name:WARE
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 1:1750 SANTA MARGARITA ST
Mailing Address - Street 2:115
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-0887
Mailing Address - Country:US
Mailing Address - Phone:702-245-5097
Mailing Address - Fax:
Practice Address - Street 1:1750 SANTA MARGARITA ST
Practice Address - Street 2:115
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-0887
Practice Address - Country:US
Practice Address - Phone:702-245-5097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-27
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV$$$$$$$$$Medicaid