MEDICARE: PRINCESS PERSONAL 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	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1861996324
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRINCESS PERSONAL CARE , LLC

Provider Business Mailing Address
First Line	:	4640 W CHARLESTON BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89102-1503
Country	:	US
Telephone Number	:	702-822-1400
Fax Number	:

Provider Business Practice Location Address
First Line	:	4640 W CHARLESTON BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89102-1503
Country	:	US
Telephone Number	:	702-822-1400
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	OYIBO IGBOAMAZU
Credential	:
Telephone Number	:	702-327-9012

Provider Enumeration Date	:	03/20/2018
Last Update Date	:	03/20/2018

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