MEDICARE: SEA BREEZE WELLNESS CENTER LTD

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	261QR0401X	Comprehensive Outpatient Rehabilitation Facility (CORF)	20150212685-92	NV

General Provider Information

NPI Number	:	1366820961
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SEA BREEZE WELLNESS CENTER LTD

Provider Business Mailing Address
First Line	:	2021 S JONES BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-3137
Country	:	US
Telephone Number	:	702-202-0099
Fax Number	:	702-778-7632

Provider Business Practice Location Address
First Line	:	2021 S JONES BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-3137
Country	:	US
Telephone Number	:	702-202-0099
Fax Number	:	702-778-7632

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MATTHEW O OKEKE
Credential	:	MD
Telephone Number	:	702-202-0099

Provider Enumeration Date	:	05/14/2015
Last Update Date	:	05/26/2015

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