Healthcare Provider Details

I. General information

NPI: 1487081048
Provider Name (Legal Business Name): SHAMLOO BLUE SKY TREATMENT CENTER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2013
Last Update Date: 10/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3150 N TENAYA WAY SUITE 510
LAS VEGAS NV
89128-0443
US

IV. Provider business mailing address

PO BOX 370457
LAS VEGAS NV
89137-0457
US

V. Phone/Fax

Practice location:
  • Phone: 702-453-3799
  • Fax:
Mailing address:
  • Phone: 702-453-3799
  • Fax: 702-453-5741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number13639
License Number StateNV

VIII. Authorized Official

Name: LORI LABRECQUE
Title or Position: ACCTS. MGR
Credential:
Phone: 702-453-3799