MEDICARE: WHOLE LIFE HEALTH SUPPORT SERVICES

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	251S00000X	Community/Behavioral Health Agency	20111426158	NV

General Provider Information

NPI Number	:	1164717484
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WHOLE LIFE HEALTH SUPPORT SERVICES

Provider Business Mailing Address
First Line	:	7124 DIVING PETRELS PL
Second Line	:
City	:	N LAS VEGAS
State	:	NV
Zip	:	89084-2353
Country	:	US
Telephone Number	:	702-321-6222
Fax Number	:

Provider Business Practice Location Address
First Line	:	2525 N DECATUR BLVD STE 2
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89108-2976
Country	:	US
Telephone Number	:	702-321-6222
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MICHELLE JACKSON
Credential	:
Telephone Number	:	702-321-6222

Provider Enumeration Date	:	06/15/2011
Last Update Date	:	05/26/2015

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