Healthcare Provider Details

I. General information

NPI: 1033173372
Provider Name (Legal Business Name): JAY DEE MELLETTE ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

980 KELLY JOHNSON DR
LAS VEGAS NV
89119-3785
US

IV. Provider business mailing address

7123 S DURANGO DR UNIT 303
LAS VEGAS NV
89113-2064
US

V. Phone/Fax

Practice location:
  • Phone: 702-352-0200
  • Fax: 702-891-1707
Mailing address:
  • Phone: 702-203-0675
  • Fax: 702-891-1717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0506040
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: