=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861908279
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. DURAY LASHAUN SOLES
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/20/2017
-----------------------------------------------------
Last Update Date | 12/20/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3095 CANTABRIA CT
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89141-3507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-209-6333
-----------------------------------------------------
Fax | 609-209-6333
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3095 CANTABRIA CT
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89141-3507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-209-6333
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------