MEDICARE: BROKENSHELLS WELLNESS CENTER LLC

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	106H00000X	Marriage & Family Therapist

General Provider Information

NPI Number	:	1043030893
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROKENSHELLS WELLNESS CENTER LLC

Provider Business Mailing Address
First Line	:	3895 QUADREL ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89129-5507
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3895 QUADREL ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89129-5507
Country	:	US
Telephone Number	:	404-428-0019
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JAZMINE SMITH
Credential	:	MFT
Telephone Number	:	404-428-0019

Provider Enumeration Date	:	10/16/2024
Last Update Date	:	10/16/2024

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