MEDICARE: MR. JAY DEE MELLETTE ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	0506040	NV

General Provider Information

NPI Number	:	1033173372
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JAY DEE MELLETTE ATC

Provider Business Mailing Address
First Line	:	7123 S DURANGO DR UNIT 303
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89113-2064
Country	:	US
Telephone Number	:	702-203-0675
Fax Number	:	702-891-1717

Provider Business Practice Location Address
First Line	:	980 KELLY JOHNSON DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-3785
Country	:	US
Telephone Number	:	702-352-0200
Fax Number	:	702-891-1707

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/13/2006
Last Update Date	:	07/08/2007

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