Healthcare Provider Details

I. General information

NPI: 1669629853
Provider Name (Legal Business Name): JON SORELLE SURGICAL, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2008
Last Update Date: 03/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

880 SEVEN HILLS DR SUITE 140
HENDERSON NV
89052-4371
US

IV. Provider business mailing address

4131 DIRECTORS ROW PO BOX 924587
HOUSTON TX
77092-8703
US

V. Phone/Fax

Practice location:
  • Phone: 702-889-4263
  • Fax:
Mailing address:
  • Phone: 713-586-6705
  • Fax: 713-586-6752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0105X
TaxonomySurgery of the Hand (Surgery) Physician
License Number12562
License Number StateNV

VIII. Authorized Official

Name: MS. LINDA CAROL KELLNER
Title or Position: DIRECTOR OF MEDICAL CREDENTIALS
Credential: DMC
Phone: 713-586-6705