Basic Information
| Provider Information | |||||||||
| NPI: | 1962793372 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEREZ | ||||||||
| FirstName: | EDNA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2965 S JONES BLVD | ||||||||
| Address2: | STE D | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891465629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7027338098 | ||||||||
| FaxNumber: | 7023956457 | ||||||||
| Practice Location | |||||||||
| Address1: | 2965 S JONES BLVD | ||||||||
| Address2: | STE D | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891465629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7027338098 | ||||||||
| FaxNumber: | 7023956457 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2011 | ||||||||
| LastUpdateDate: | 05/30/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 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 | 372500000X | NV | N | Nursing Service Related Providers | Chore Provider | 372600000X | NV | N | Nursing Service Related Providers | Adult Companion |
No ID Information.