MEDICARE: MIMI'S CARE HOME, 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	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1184111007
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIMI'S CARE HOME, LLC

Provider Business Mailing Address
First Line	:	3055 S PIONEER WAY
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-3244
Country	:	US
Telephone Number	:	702-767-5220
Fax Number	:

Provider Business Practice Location Address
First Line	:	3055 S PIONEER WAY
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-3244
Country	:	US
Telephone Number	:	702-767-5220
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	MS. MIMI ASFAW
Credential	:
Telephone Number	:	702-767-5220

Provider Enumeration Date	:	04/16/2018
Last Update Date	:	06/16/2018

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