MEDICARE: MR. JEREMIAS DEWAYNE CARTER

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	261Q00000X	Clinic/Center		NV

General Provider Information

NPI Number	:	1396434775
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JEREMIAS DEWAYNE CARTER

Provider Business Mailing Address
First Line	:	800 N RAINBOW BLVD STE 145
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89107-1191
Country	:	US
Telephone Number	:	725-204-9155
Fax Number	:

Provider Business Practice Location Address
First Line	:	800 N RAINBOW BLVD STE 145
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89107-1191
Country	:	US
Telephone Number	:	725-204-9155
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/02/2023
Last Update Date	:	06/02/2026

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