MEDICARE: MR. DONALD RAY MCCALL JR.

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	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1073935268
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DONALD RAY MCCALL JR.

Provider Business Mailing Address
First Line	:	2117 KENNETH RD
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89030-6632
Country	:	US
Telephone Number	:	702-527-0633
Fax Number	:

Provider Business Practice Location Address
First Line	:	2117 KENNETH RD
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89030-6632
Country	:	US
Telephone Number	:	702-527-0633
Fax Number	:

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

Provider Enumeration Date	:	01/08/2014
Last Update Date	:	01/08/2014

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