MEDICARE: LAS VEGAS GROUP HOME 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	310400000X	Assisted Living Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1821764135
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAS VEGAS GROUP HOME LLC

Provider Business Mailing Address
First Line	:	1680 SOMBRERO DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89169-2564
Country	:	US
Telephone Number	:	702-209-2580
Fax Number	:	702-202-4093

Provider Business Practice Location Address
First Line	:	1680 SOMBRERO DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89169-2564
Country	:	US
Telephone Number	:	702-209-2580
Fax Number	:	702-202-4093

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	JOE RABIN
Credential	:
Telephone Number	:	818-335-2278

Provider Enumeration Date	:	08/17/2021
Last Update Date	:	08/17/2021

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