MEDICARE: PRIMECARE FACILITY

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	261QM0850X	Adult Mental Health Clinic/Center	NB20101850035	NV

General Provider Information

NPI Number	:	1942505755
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIMECARE FACILITY

Provider Business Mailing Address
First Line	:	4920 RONAN DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89110
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4920 RONAN DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89110-4736
Country	:	US
Telephone Number	:	702-203-2381
Fax Number	:

Authorized Official
Title or Position	:	OWNER/ADMINISTRATOR
Name	:	JOSEFINA R ADAMS
Credential	:
Telephone Number	:	702-203-2381

Provider Enumeration Date	:	01/26/2011
Last Update Date	:	01/26/2011

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Directions to “PRIMECARE FACILITY ” Practice Location

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