Healthcare Provider Details

I. General information

NPI: 1487145371
Provider Name (Legal Business Name): JERU-MAALIK LOLLIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2018
Last Update Date: 05/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3235 S EASTERN AVE
LAS VEGAS NV
89169-3310
US

IV. Provider business mailing address

3235 S EASTERN AVE
LAS VEGAS NV
89169-3310
US

V. Phone/Fax

Practice location:
  • Phone: 702-490-9009
  • Fax:
Mailing address:
  • Phone: 702-490-9009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: