Provider Demographics
NPI:1316560493
Name:PARKS, ELIJAH ZACHERY
Entity Type:Individual
Prefix:
First Name:ELIJAH
Middle Name:ZACHERY
Last Name:PARKS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ELIJAH
Other - Middle Name:ZACHERY
Other - Last Name:PARKS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2406 MOROCCO AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89031-0945
Mailing Address - Country:US
Mailing Address - Phone:702-845-1262
Mailing Address - Fax:
Practice Address - Street 1:2406 MOROCCO AVE
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89031-0945
Practice Address - Country:US
Practice Address - Phone:702-845-1262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-22
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide