Provider Demographics
NPI:1366618019
Name:PROCARE MEDICAL GROUP LLC
Entity type:Organization
Organization Name:PROCARE MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:
Authorized Official - Last Name:GANTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-396-6000
Mailing Address - Street 1:6870 S RAINBOW BLVD
Mailing Address - Street 2:SUITE 106 & 107
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89118-2106
Mailing Address - Country:US
Mailing Address - Phone:702-396-6000
Mailing Address - Fax:702-396-6001
Practice Address - Street 1:6870 S RAINBOW BLVD
Practice Address - Street 2:SUITE 106 & 107
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89118-2106
Practice Address - Country:US
Practice Address - Phone:702-396-6000
Practice Address - Fax:702-396-6001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV12502207Q00000X, 261QU0200X
261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV12502OtherLICENSE NUMBER
NV12502OtherLICENSE NUMBER
BT9475117OtherDEA