Provider Demographics
NPI:1114631389
Name:MARTIN PERDOMO, JUAN MANUEL
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:MANUEL
Last Name:MARTIN PERDOMO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4715 VEGAS VALLEY DR UNIT 10
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-7944
Mailing Address - Country:US
Mailing Address - Phone:702-366-3283
Mailing Address - Fax:
Practice Address - Street 1:4715 VEGAS VALLEY DR UNIT 10
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-7944
Practice Address - Country:US
Practice Address - Phone:702-366-3283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-11
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant