Healthcare Provider Details

I. General information

NPI: 1528717543
Provider Name (Legal Business Name): KEESHA MCCLOUD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KEESHA WALLACE

II. Dates (important events)

Enumeration Date: 03/18/2022
Last Update Date: 03/18/2022
Certification Date: 03/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2869 CHALK MOUNTAIN CT
LAS VEGAS NV
89142-1864
US

IV. Provider business mailing address

2869 CHALK MOUNTAIN CT
LAS VEGAS NV
89142-1864
US

V. Phone/Fax

Practice location:
  • Phone: 725-256-1108
  • Fax:
Mailing address:
  • Phone: 725-256-1108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: