MEDICARE: VEGAS SENIOR HOME CARE 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	320700000X	Physical Disabilities Residential Treatment Facility
2	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1578046132
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VEGAS SENIOR HOME CARE LLC

Provider Business Mailing Address
First Line	:	1401 ARVILLE ST STE B
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89102-0537
Country	:	US
Telephone Number	:	702-738-0844
Fax Number	:	702-527-7698

Provider Business Practice Location Address
First Line	:	1130 SHARON RD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89106-2036
Country	:	US
Telephone Number	:	702-738-0514
Fax Number	:	702-527-7698

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. MYONG WOOK KIM
Credential	:
Telephone Number	:	702-738-0514

Provider Enumeration Date	:	09/10/2018
Last Update Date	:	09/10/2018

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