Provider Demographics
NPI:1497913420
Name:MCDANIEL, CLEAUTRY H JR
Entity Type:Individual
Prefix:MR
First Name:CLEAUTRY
Middle Name:H
Last Name:MCDANIEL
Suffix:JR
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 1:501 S RANCHO DR
Mailing Address - Street 2:#E33
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-4828
Mailing Address - Country:US
Mailing Address - Phone:704-476-4987
Mailing Address - Fax:702-541-8377
Practice Address - Street 1:501 S RANCHO DR
Practice Address - Street 2:#E33
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4828
Practice Address - Country:US
Practice Address - Phone:704-476-4987
Practice Address - Fax:702-541-8377
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-27
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV30-0474098OtherFEDERAL TAX ID