MEDICARE: SANDRA FUENTES

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	3747P1801X	Personal Care Attendant

General Provider Information

NPI Number	:	1215411152
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANDRA FUENTES

Provider Business Mailing Address
First Line	:	6128 W SAHARA AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-3051
Country	:	US
Telephone Number	:	702-598-2048
Fax Number	:

Provider Business Practice Location Address
First Line	:	4831 E COLORADO AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89104-5811
Country	:	US
Telephone Number	:	702-406-6966
Fax Number	:

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

Provider Enumeration Date	:	09/17/2018
Last Update Date	:	09/17/2018

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