MEDICARE: DMARIO RANDY TRAVELL COLEMAN

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	3747P1801X	Personal Care Attendant		NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1972071330
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DMARIO RANDY TRAVELL COLEMAN

Provider Business Mailing Address
First Line	:	3786 IDLEWOOD AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89115-8143
Country	:	US
Telephone Number	:	702-635-7987
Fax Number	:

Provider Business Practice Location Address
First Line	:	3786 IDLEWOOD AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89115-8143
Country	:	US
Telephone Number	:	702-635-7987
Fax Number	:

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

Provider Enumeration Date	:	11/04/2018
Last Update Date	:	11/04/2018

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