Healthcare Provider Details

I. General information

NPI: 1083201602
Provider Name (Legal Business Name): YAIMA LA ROSA JAEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2020
Last Update Date: 12/29/2020
Certification Date: 12/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3047 KENNEWICK DR
LAS VEGAS NV
89121-2386
US

IV. Provider business mailing address

2350 S JONES BLVD
LAS VEGAS NV
89146-3103
US

V. Phone/Fax

Practice location:
  • Phone: 702-423-3726
  • Fax:
Mailing address:
  • Phone: 702-510-9982
  • Fax: 702-920-8270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: