Healthcare Provider Details

I. General information

NPI: 1538553599
Provider Name (Legal Business Name): IDA PEARL CONNORS H.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2015
Last Update Date: 03/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8640 CASTLE HILL AVE
LAS VEGAS NV
89129-7645
US

IV. Provider business mailing address

8640 CASTLE HILL AVE
LAS VEGAS NV
89129-7645
US

V. Phone/Fax

Practice location:
  • Phone: 702-254-8721
  • Fax: 702-254-8726
Mailing address:
  • Phone: 702-254-8721
  • Fax: 702-254-8726

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: