MEDICARE: PREVENTATIVE DIAGNOSTIC CENTER 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	2085B0100X	Body Imaging Physician

General Provider Information

NPI Number	:	1891489050
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREVENTATIVE DIAGNOSTIC CENTER LLC

Provider Business Mailing Address
First Line	:	6620 S TENAYA WAY STE 120
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89113-1962
Country	:	US
Telephone Number	:	702-534-7900
Fax Number	:

Provider Business Practice Location Address
First Line	:	6620 S TENAYA WAY STE 120
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89113-1962
Country	:	US
Telephone Number	:	702-534-7900
Fax Number	:

Authorized Official
Title or Position	:	MANAGER/OWNER
Name	:	KEVIN BLAIR
Credential	:
Telephone Number	:	702-493-8816

Provider Enumeration Date	:	06/08/2023
Last Update Date	:	06/08/2023

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