Provider Demographics
NPI:1073049367
Name:WELL CARE MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:WELL CARE MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MAE
Authorized Official - Middle Name:
Authorized Official - Last Name:LUECK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:747-273-6179
Mailing Address - Street 1:7488 W SAHARA AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-2740
Mailing Address - Country:US
Mailing Address - Phone:702-641-1240
Mailing Address - Fax:
Practice Address - Street 1:6330 MCLEOD DR STE 3
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-4431
Practice Address - Country:US
Practice Address - Phone:747-273-6179
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-04
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV207R00000X, 208D00000X, 261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1073049367Medicaid