MEDICARE: CARE COMMUNITY CORNER

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1356888358
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CARE COMMUNITY CORNER

Provider Business Mailing Address
First Line	:	1052 W OWENS AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89106-2520
Country	:	US
Telephone Number	:	702-877-9850
Fax Number	:

Provider Business Practice Location Address
First Line	:	1052 W OWENS AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89106-2520
Country	:	US
Telephone Number	:	702-877-9850
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MRS. PENNY A JACKSON
Credential	:	M.A
Telephone Number	:	702-860-5190

Provider Enumeration Date	:	01/27/2017
Last Update Date	:	01/27/2017

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Directions to “CARE COMMUNITY CORNER ” Practice Location

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