Healthcare Provider Details

I. General information

NPI: 1518288190
Provider Name (Legal Business Name): MR. JOHN W HARRELL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2010
Last Update Date: 06/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4813 BERESIK CIR
LAS VEGAS NV
89115-2228
US

IV. Provider business mailing address

4813 BERESIK CIRCLE
NELLIS AFB NV
89115
US

V. Phone/Fax

Practice location:
  • Phone: 228-424-1438
  • Fax:
Mailing address:
  • Phone: 228-424-1438
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License NumberRN 9204030
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: