MEDICARE: MISSIO DEI ENTERPRISES 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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1265007306
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MISSIO DEI ENTERPRISES LLC

Provider Business Mailing Address
First Line	:	3648 BELLA LEGATO AVE
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89081-4044
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3648 BELLA LEGATO AVE
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89081-4044
Country	:	US
Telephone Number	:	702-325-9226
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	BRENDA BRAAM
Credential	:
Telephone Number	:	702-325-9226

Provider Enumeration Date	:	05/21/2021
Last Update Date	:	05/21/2021

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