MEDICARE: PRIME MEDICAL 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	261QH0100X	Health Service Clinic/Center

General Provider Information

NPI Number	:	1043936990
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIME MEDICAL CENTER LLC

Provider Business Mailing Address
First Line	:	2621 W CHARLESTON BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89102-2121
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1917 ROSE CORAL AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89106-1807
Country	:	US
Telephone Number	:	786-870-2904
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	JORGE PUEBLA ISAAC
Credential	:
Telephone Number	:	786-870-2904

Provider Enumeration Date	:	10/12/2022
Last Update Date	:	06/10/2025

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Directions to “PRIME MEDICAL CENTER LLC ” Practice Location

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