MEDICARE: WAGONEER GROUP CARE

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	311ZA0620X	Adult Care Home Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	9005046915	OTHER	NV	9005046915

General Provider Information

NPI Number	:	1245785203
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAGONEER GROUP CARE

Provider Business Mailing Address
First Line	:	3705 WAGONEER DR
Second Line	:
City	:	RENO
State	:	NV
Zip	:	89502-5917
Country	:	US
Telephone Number	:	775-409-5675
Fax Number	:	775-800-1836

Provider Business Practice Location Address
First Line	:	3705 WAGONEER DR
Second Line	:
City	:	RENO
State	:	NV
Zip	:	89502-5917
Country	:	US
Telephone Number	:	775-409-5675
Fax Number	:	775-800-1836

Authorized Official
Title or Position	:	OWNER ADMINISTRATOR
Name	:	BRENDA CLARETE FINK
Credential	:
Telephone Number	:	775-825-6876

Provider Enumeration Date	:	08/19/2016
Last Update Date	:	08/19/2016

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Directions to “WAGONEER GROUP CARE ” Practice Location

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