MEDICARE: MRS. JANUARY BLUE

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	311ZA0620X	Adult Care Home Facility	5002AGC-12	NV

General Provider Information

NPI Number	:	1750782595
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JANUARY BLUE

Provider Business Mailing Address
First Line	:	2608 WOOLY ROSE AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89106-1466
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1013 STONEYPEAK AVE
Second Line	:
City	:	N LAS VEGAS
State	:	NV
Zip	:	89081-3239
Country	:	US
Telephone Number	:	702-478-5252
Fax Number	:

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

Provider Enumeration Date	:	09/11/2014
Last Update Date	:	09/15/2014

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Directions to “ MRS. JANUARY BLUE ” Practice Location

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