Healthcare Provider Details

I. General information

NPI: 1073049367
Provider Name (Legal Business Name): WELL CARE MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2017
Last Update Date: 01/28/2021
Certification Date: 01/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6330 MCLEOD DR STE 3
LAS VEGAS NV
89120-4431
US

IV. Provider business mailing address

7488 W SAHARA AVE
LAS VEGAS NV
89117-2740
US

V. Phone/Fax

Practice location:
  • Phone: 747-273-6179
  • Fax:
Mailing address:
  • Phone: 702-641-1240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateNV

VIII. Authorized Official

Name: MAE LUECK
Title or Position: CEO
Credential:
Phone: 747-273-6179