MEDICARE: PROVENANCE HEALTHCARE 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	170300000X	Genetic Counselor (M.S.)	OTHER	NV

General Provider Information

NPI Number	:	1316322738
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVENANCE HEALTHCARE LLC

Provider Business Mailing Address
First Line	:	5155 S DURANGO DR STE 103
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89113-0175
Country	:	US
Telephone Number	:	702-478-2524
Fax Number	:	702-735-9074

Provider Business Practice Location Address
First Line	:	5155 S DURANGO DR STE 103
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89113-0175
Country	:	US
Telephone Number	:	702-478-2524
Fax Number	:	702-735-9074

Authorized Official
Title or Position	:	OWNER OPERATOR
Name	:	MARK L BLACK
Credential	:
Telephone Number	:	702-478-2524

Provider Enumeration Date	:	07/27/2015
Last Update Date	:	07/27/2015

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