Provider Demographics
NPI:1821531732
Name:COMFORT CARE CLINIC LLC
Entity Type:Organization
Organization Name:COMFORT CARE CLINIC LLC
Other - Org Name:COMFORT CARE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MS
Authorized Official - First Name:DYAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:WEBB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-754-2933
Mailing Address - Street 1:2121 N JONES BLVD
Mailing Address - Street 2:#206
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89108-3300
Mailing Address - Country:US
Mailing Address - Phone:404-754-2933
Mailing Address - Fax:
Practice Address - Street 1:2121 N JONES BLVD
Practice Address - Street 2:#206
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89108-3300
Practice Address - Country:US
Practice Address - Phone:404-754-2933
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-24
Last Update Date:2016-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV20161596632251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV14Medicaid