Organization
PROVENANCE HEALTHCARE LLC
Active
Organization
PROVENANCE HEALTHCARE LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MARK L BLACK (OWNER OPERATOR)
(702) 478-2524
Entity
Organization
Contact information
Practice address
5155 S DURANGO DR STE 103, LAS VEGAS, NV 89113-0175
(702) 478-2524
(702) 735-9074
Mailing address
5155 S DURANGO DR STE 103, LAS VEGAS, NV 89113-0175
(702) 478-2524
(702) 735-9074
Taxonomy
Speciality
Code
Description
License number
State
170300000X
Genetic Counselor (M.S.)
Primary
OTHER
NV
Other
Enumeration date
07/27/2015
Last updated
07/27/2015
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