Provenance Healthcare LLC

Primary specialty

Genetic Counselor (M.S.)Taxonomy code 170300000X

License

OTHER Issued in NV

Legal business name

PROVENANCE HEALTHCARE LLC

Practice address

5155 S Durango Dr Ste 103
Las Vegas, NV 89113-0175

Phone

(702) 478-2524

Fax

(702) 735-9074

NPI assigned

Jul 27, 2015

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mark L Black

Title

Owner Operator

Phone

(702) 478-2524

Specialties & licenses 1

Addresses

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1437955200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1437955200000",
    "number": "1316322738",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5155 S DURANGO DR STE 103",
            "city": "LAS VEGAS",
            "state": "NV",
            "postal_code": "891130175",
            "telephone_number": "702-478-2524",
            "fax_number": "702-735-9074"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5155 S DURANGO DR STE 103",
            "city": "LAS VEGAS",
            "state": "NV",
            "postal_code": "891130175",
            "telephone_number": "702-478-2524",
            "fax_number": "702-735-9074"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVENANCE HEALTHCARE LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-07-27",
        "last_updated": "2015-07-27",
        "status": "A",
        "authorized_official_last_name": "BLACK",
        "authorized_official_first_name": "MARK",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "OWNER OPERATOR",
        "authorized_official_telephone_number": "702-478-2524"
    },
    "taxonomies": [
        {
            "code": "170300000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Genetic Counselor, MS",
            "state": "NV",
            "license": "OTHER",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Providers in Las Vegas, NV by specialty
• Genetic Counselor (M.S.) in Nevada

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 27, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.