MEDICARE: MARYLOU POAGE

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	:	1912527938
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARYLOU POAGE

Provider Business Mailing Address
First Line	:	3430 E FLAMINGO RD STE 251
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-5003
Country	:	US
Telephone Number	:	702-444-4686
Fax Number	:

Provider Business Practice Location Address
First Line	:	2165 E ROCHELLE AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-5438
Country	:	US
Telephone Number	:	702-826-0383
Fax Number	:

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

Provider Enumeration Date	:	04/20/2020
Last Update Date	:	04/20/2020

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Directions to “ MARYLOU POAGE ” Practice Location

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