Provider Demographics
NPI:1447794466
Name:INCERA LLC
Entity Type:Organization
Organization Name:INCERA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HORACE
Authorized Official - Middle Name:
Authorized Official - Last Name:GUERRA
Authorized Official - Suffix:IV
Authorized Official - Credentials:MD
Authorized Official - Phone:702-809-1171
Mailing Address - Street 1:4030 S JONES BLVD
Mailing Address - Street 2:#32169
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89173-8801
Mailing Address - Country:US
Mailing Address - Phone:702-624-5441
Mailing Address - Fax:
Practice Address - Street 1:10885 S EASTERN AVE
Practice Address - Street 2:#100
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-5857
Practice Address - Country:US
Practice Address - Phone:702-419-9977
Practice Address - Fax:702-921-0222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-09
Last Update Date:2017-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV11608207Q00000X, 2083P0011X, 208M00000X
UT6826335-1205208M00000X
NVAPRN001889363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric MedicineGroup - Single Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Single Specialty
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV110439Medicare PIN