Healthcare Provider Details

I. General information

NPI: 1396203600
Provider Name (Legal Business Name): TJL8 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2019
Last Update Date: 03/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2075 E FLAMINGO RD
LAS VEGAS NV
89119-5188
US

IV. Provider business mailing address

8820 GREENSBORO LN
LAS VEGAS NV
89134-0523
US

V. Phone/Fax

Practice location:
  • Phone: 702-369-7571
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. FRED THOMAS LEE
Title or Position: OWNER
Credential: MD
Phone: 702-321-9080