Provider Demographics
NPI:1043876832
Name:GOUTSALIOUK, ELENA
Entity Type:Individual
Prefix:
First Name:ELENA
Middle Name:
Last Name:GOUTSALIOUK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:87 LOST MOUNTAIN CT
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-1755
Mailing Address - Country:US
Mailing Address - Phone:702-321-9458
Mailing Address - Fax:
Practice Address - Street 1:2780 S JONES BLVD STE 130
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-5641
Practice Address - Country:US
Practice Address - Phone:702-463-0085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-16
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant