Provider Demographics
NPI:1316322738
Name:PROVENANCE HEALTHCARE LLC
Entity type:Organization
Organization Name:PROVENANCE HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:L
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-478-2524
Mailing Address - Street 1:5155 S DURANGO DR STE 103
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-0175
Mailing Address - Country:US
Mailing Address - Phone:702-478-2524
Mailing Address - Fax:702-735-9074
Practice Address - Street 1:5155 S DURANGO DR STE 103
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89113-0175
Practice Address - Country:US
Practice Address - Phone:702-478-2524
Practice Address - Fax:702-735-9074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-27
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVOTHER170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes170300000XOther Service ProvidersGenetic Counselor, MSGroup - Single Specialty