MEDICARE: DEJA AXARIA TERRY

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	253Z00000X	In Home Supportive Care Agency
2	3747P1801X	Personal Care Attendant

General Provider Information

NPI Number	:	1871094888
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEJA AXARIA TERRY

Provider Business Mailing Address
First Line	:	1600 E DESERT INN RD STE 120
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89169-2505
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4640 VEGAS VALLEY DR APT 1095
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-7912
Country	:	US
Telephone Number	:	702-910-8911
Fax Number	:

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

Provider Enumeration Date	:	02/24/2018
Last Update Date	:	02/24/2018

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Directions to “ DEJA AXARIA TERRY ” Practice Location

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