MEDICARE: MR. FRANKLIN DALE HEATH JR. PROGRAM DIRECTOR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1003335225
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. FRANKLIN DALE HEATH JR. PROGRAM DIRECTOR

Provider Business Mailing Address
First Line	:	3852 PALOS VERDES ST APT 32
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-6910
Country	:	US
Telephone Number	:	702-328-2023
Fax Number	:

Provider Business Practice Location Address
First Line	:	3852 PALOS VERDES ST APT 32
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-6910
Country	:	US
Telephone Number	:	702-328-2023
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/19/2017
Last Update Date	:	07/21/2022

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