Provider Demographics
NPI:1760107106
Name:BALL, SHANTE JEROME
Entity Type:Individual
Prefix:
First Name:SHANTE
Middle Name:JEROME
Last Name:BALL
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 1:1420 TREE LINE DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89142-0813
Mailing Address - Country:US
Mailing Address - Phone:323-942-7074
Mailing Address - Fax:
Practice Address - Street 1:1420 TREE LINE DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89142-0813
Practice Address - Country:US
Practice Address - Phone:323-942-7074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-07
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant