Healthcare Provider Details

I. General information

NPI: 1295047488
Provider Name (Legal Business Name): MRS. LORI L DAMICO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2010
Last Update Date: 07/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1432 VISTA DEL CIUDAD DR
MESQUITE NV
89027-2203
US

IV. Provider business mailing address

1432 VISTA DEL CIUDAD DR
MESQUITE NV
89027-2203
US

V. Phone/Fax

Practice location:
  • Phone: 702-346-5941
  • Fax: 702-346-5941
Mailing address:
  • Phone: 702-346-5941
  • Fax: 702-346-5941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberNV20101444298
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: