Provider Demographics
NPI:1467926816
Name:MCCOWAN, MACEO R
Entity Type:Individual
Prefix:
First Name:MACEO
Middle Name:R
Last Name:MCCOWAN
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 1:2110 E FLAMINGO RD STE 110
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-5191
Mailing Address - Country:US
Mailing Address - Phone:725-222-7203
Mailing Address - Fax:
Practice Address - Street 1:5055 E CHARLESTON BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89104-6471
Practice Address - Country:US
Practice Address - Phone:661-468-6183
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-18
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant