Basic Information
| Provider Information | |||||||||
| NPI: | 1750684841 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MICHELL | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 N RAINBOW BLVD | ||||||||
| Address2: | 212 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891071189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022933888 | ||||||||
| FaxNumber: | 7022933664 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 N RAINBOW BLVD | ||||||||
| Address2: | 212 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891071189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022933888 | ||||||||
| FaxNumber: | 7022933664 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2010 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302F00000X | 6048PCS-6 | NV | N | Managed Care Organizations | Exclusive Provider Organization | 372500000X | 6048PCS-6 | NV | N | Nursing Service Related Providers | Chore Provider | 374U00000X | 6048PCS-6 | NV | N | Nursing Service Related Providers | Home Health Aide | 251E00000X | 6048PCS-6 | NV | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 1538546635 | 05 | NV | MEDICAID |