Healthcare Provider Details

I. General information

NPI: 1194445569
Provider Name (Legal Business Name): STAN ROMMEL SHAKUR-BEAR LEACHMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2022
Last Update Date: 12/31/2024
Certification Date: 12/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3435 W CRAIG RD B
NOTH LAS VEGAS NV
89012
US

IV. Provider business mailing address

3171 KEY LARGO DR APT 104
LAS VEGAS NV
89120-1109
US

V. Phone/Fax

Practice location:
  • Phone: 702-826-0312
  • Fax:
Mailing address:
  • Phone: 702-826-0312
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: