Provider Demographics
NPI:1194445569
Name:LEACHMAN, STAN ROMMEL SHAKUR-BEAR
Entity type:Individual
Prefix:
First Name:STAN
Middle Name:ROMMEL SHAKUR-BEAR
Last Name:LEACHMAN
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 1:3171 KEY LARGO DR APT 104
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-1109
Mailing Address - Country:US
Mailing Address - Phone:702-826-0312
Mailing Address - Fax:
Practice Address - Street 1:3435 W CRAIG RD B
Practice Address - Street 2:
Practice Address - City:NOTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89012
Practice Address - Country:US
Practice Address - Phone:702-826-0312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-29
Last Update Date:2024-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No372600000XNursing Service Related ProvidersAdult Companion
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
No374U00000XNursing Service Related ProvidersHome Health Aide
No376J00000XNursing Service Related ProvidersHomemaker