MEDICARE: PMD VENTURES 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
2	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1316585177
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PMD VENTURES LLC

Provider Business Mailing Address
First Line	:	9867 ANTELOPE CANYON AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89147-7739
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9867 ANTELOPE CANYON AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89147-7739
Country	:	US
Telephone Number	:	702-904-0260
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	DAVID HARDY
Credential	:
Telephone Number	:	702-904-0260

Provider Enumeration Date	:	12/11/2019
Last Update Date	:	12/11/2019

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