MEDICARE: WHOLE LIFE PERSONAL CARE AGENCY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	253Z00000X	In Home Supportive Care Agency	NV201801659566	NV

General Provider Information

NPI Number	:	1033606801
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WHOLE LIFE PERSONAL CARE AGENCY

Provider Business Mailing Address
First Line	:	2525 N DECATUR BLVD STE 2AND5
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89108-2975
Country	:	US
Telephone Number	:	702-982-3636
Fax Number	:	702-982-3737

Provider Business Practice Location Address
First Line	:	2525 N DECATUR BLVD STE 2AND5
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89108-2975
Country	:	US
Telephone Number	:	702-982-3636
Fax Number	:	702-982-3737

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	LUCY M JACKSON
Credential	:	MS
Telephone Number	:	702-412-5175

Provider Enumeration Date	:	04/17/2018
Last Update Date	:	04/17/2018

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Directions to “WHOLE LIFE PERSONAL CARE AGENCY ” Practice Location

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