MEDICARE: ISSAC POAGS

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1124563416
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ISSAC POAGS

Provider Business Mailing Address
First Line	:	650 E AZURE AVE APT 2059
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89081-6876
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	650 E AZURE AVE APT 2059
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89081-6876
Country	:	US
Telephone Number	:	708-288-5256
Fax Number	:

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

Provider Enumeration Date	:	12/22/2016
Last Update Date	:	12/22/2016

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