Basic Information
| Provider Information | |||||||||
| NPI: | 1871975219 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JIMENEZ | ||||||||
| FirstName: | EDGAR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2001 S JONES BLVD | ||||||||
| Address2: | STE E3 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891463182 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2860 E FLAMINGO RD STE K | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891215270 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023185005 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2015 | ||||||||
| 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 | 253Z00000X | 1017014744001 | NV | N | Agencies | In Home Supportive Care | 253Z00000X | N | Agencies | In Home Supportive Care | 253Z00000X | 1710058573 | NV | Y | Agencies | In Home Supportive Care |
ID Information
| ID | Type | State | Issuer | Description | 1710058573 | 01 | NV | PERSONAL CARE | OTHER | 1710058573 | 05 | NV | MEDICAID |