Provider Demographics
NPI:1750684841
Name:MICHELL, CHARLES
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:
Last Name:MICHELL
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 1:800 N RAINBOW BLVD
Mailing Address - Street 2:212
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89107-1189
Mailing Address - Country:US
Mailing Address - Phone:702-293-3888
Mailing Address - Fax:702-293-3664
Practice Address - Street 1:800 N RAINBOW BLVD
Practice Address - Street 2:212
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89107-1189
Practice Address - Country:US
Practice Address - Phone:702-293-3888
Practice Address - Fax:702-293-3664
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-10
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV6048PCS-6302F00000X, 372500000X, 374U00000X, 251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No302F00000XManaged Care OrganizationsExclusive Provider Organization
No372500000XNursing Service Related ProvidersChore Provider
No374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1538546635Medicaid