MEDICARE: EVENING STAR MEDICAL GROUP LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1225991938
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVENING STAR MEDICAL GROUP LLC

Provider Business Mailing Address
First Line	:	3600 CAMBRIDGE ST STE 102
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89169-4003
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3600 CAMBRIDGE ST STE 102
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89169-4003
Country	:	US
Telephone Number	:	347-419-1666
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	RAMEIR VICTORIANO
Credential	:
Telephone Number	:	347-419-1666

Provider Enumeration Date	:	12/09/2025
Last Update Date	:	12/09/2025

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