Basic Information
| Provider Information | |||||||||
| NPI: | 1457832388 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SOUTHARD | ||||||||
| FirstName: | SHANNON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3665 NEEDLES HWY UNIT 50D | ||||||||
| Address2: | |||||||||
| City: | LAUGHLIN | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890290226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7025368793 | ||||||||
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| Practice Location | |||||||||
| Address1: | 160 E HORIZON DR STE A | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890157934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7026443600 | ||||||||
| FaxNumber: | 7027195665 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2018 | ||||||||
| LastUpdateDate: | 08/28/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 372500000X | NV | N | Nursing Service Related Providers | Chore Provider | 372600000X | NV | N | Nursing Service Related Providers | Adult Companion | 3747A0650X | NV | N | Nursing Service Related Providers | Technician | Attendant Care Provider | 376J00000X | NV | N | Nursing Service Related Providers | Homemaker | 3747P1801X | NV | Y | Nursing Service Related Providers | Technician | Personal Care Attendant |
No ID Information.