MEDICARE: AGAVE SPECIALTY CARE, 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	311ZA0620X	Adult Care Home Facility
2	311500000X	Alzheimer Center (Dementia Center)

General Provider Information

NPI Number	:	1649086372
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AGAVE SPECIALTY CARE, LLC

Provider Business Mailing Address
First Line	:	2714 DUCK POND CT
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89074-1915
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3335 RAWHIDE ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89120-1933
Country	:	US
Telephone Number	:	725-204-9005
Fax Number	:	702-268-8925

Authorized Official
Title or Position	:	OWNER
Name	:	HOMER SIMS
Credential	:
Telephone Number	:	702-350-6300

Provider Enumeration Date	:	12/07/2024
Last Update Date	:	04/03/2025

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Directions to “AGAVE SPECIALTY CARE, LLC ” Practice Location

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