Healthcare Provider Details

I. General information

NPI: 1275958415
Provider Name (Legal Business Name): CORNELIUS DZAMESI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2014
Last Update Date: 04/03/2023
Certification Date: 04/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 KAREN AVE STE B203
LAS VEGAS NV
89109-1271
US

IV. Provider business mailing address

900 KAREN AVE STE B203
LAS VEGAS NV
89109-1271
US

V. Phone/Fax

Practice location:
  • Phone: 702-893-2002
  • Fax: 702-369-3334
Mailing address:
  • Phone: 702-893-2002
  • Fax: 702-369-3334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number2000558-062-101
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: