Healthcare Provider Details

I. General information

NPI: 1457893547
Provider Name (Legal Business Name): BILLY LEE EARL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2016
Last Update Date: 11/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 N DECATUR BLVD STE 2&3
LAS VEGAS NV
89108-2975
US

IV. Provider business mailing address

2525 N DECATUR BLVD STE 2&3
LAS VEGAS NV
89108-2975
US

V. Phone/Fax

Practice location:
  • Phone: 702-982-3636
  • Fax: 702-982-3737
Mailing address:
  • Phone: 702-982-3636
  • Fax: 702-982-3737

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code229N00000X
TaxonomyAnaplastologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: