MEDICARE: EDY AGEE

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	103K00000X	Behavior Analyst
2	171W00000X	Contractor
3	372600000X	Adult Companion
4	3747P1801X	Personal Care Attendant
5	374U00000X	Home Health Aide
6	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1114497237
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDY AGEE

Provider Business Mailing Address
First Line	:	700 W VAN BUREN AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89106-3043
Country	:	US
Telephone Number	:	808-780-1218
Fax Number	:

Provider Business Practice Location Address
First Line	:	700 W VAN BUREN AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89106-3043
Country	:	US
Telephone Number	:	808-780-1218
Fax Number	:

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

Provider Enumeration Date	:	12/01/2018
Last Update Date	:	07/18/2019

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