Healthcare Provider Details

I. General information

NPI: 1306462742
Provider Name (Legal Business Name): TOTAL CARE MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2020
Last Update Date: 06/22/2020
Certification Date: 06/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6040 S DURANGO DR STE 115
LAS VEGAS NV
89113-1792
US

IV. Provider business mailing address

3358 HILLSIDE GARDEN DR
LAS VEGAS NV
89135-2829
US

V. Phone/Fax

Practice location:
  • Phone: 310-408-8714
  • Fax:
Mailing address:
  • Phone: 310-408-8714
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JOHN DOBLE
Title or Position: ADMINISTRATOR
Credential:
Phone: 310-408-8714