Provider Demographics
NPI:1629576129
Name:PRADA PITA, JEOVANY RAFAEL
Entity Type:Individual
Prefix:
First Name:JEOVANY
Middle Name:RAFAEL
Last Name:PRADA PITA
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 1:1106 LULU AVE APT 5
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-1442
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1951 STELLA LAKE ST STE 36
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-2144
Practice Address - Country:US
Practice Address - Phone:702-595-8309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-30
Last Update Date:2018-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant