MEDICARE: MR. DEMETRIUS NELLUM LVN

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	376K00000X	Nurse's Aide	56130	MS

General Provider Information

NPI Number	:	1528344900
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DEMETRIUS NELLUM LVN

Provider Business Mailing Address
First Line	:	2101 HAYES RD APT 2007
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77077-6914
Country	:	US
Telephone Number	:	281-857-1710
Fax Number	:

Provider Business Practice Location Address
First Line	:	2101 HAYES RD APT 2007
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77077-6914
Country	:	US
Telephone Number	:	281-857-1710
Fax Number	:

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

Provider Enumeration Date	:	10/28/2011
Last Update Date	:	10/28/2011

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