Healthcare Provider Details

I. General information

NPI: 1962719625
Provider Name (Legal Business Name): CLINTON HOUSE JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2010
Last Update Date: 09/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9682 DIETERICH AVE
LAS VEGAS NV
89148-5738
US

IV. Provider business mailing address

9682 DIETAICH AVE
LAS VEGAS NV
89148
US

V. Phone/Fax

Practice location:
  • Phone: 702-300-2379
  • Fax:
Mailing address:
  • Phone: 702-300-2379
  • Fax: 702-644-6031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: