MEDICARE: ETERNITY HEALTH 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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1568956498
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ETERNITY HEALTH WELLNESS CENTER, LLC

Provider Business Mailing Address
First Line	:	6332 LEGEND FALLS ST
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89081-6621
Country	:	US
Telephone Number	:	702-272-9079
Fax Number	:

Provider Business Practice Location Address
First Line	:	6332 LEGEND FALLS ST
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89081-6621
Country	:	US
Telephone Number	:	702-272-9079
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	LACONJA BROOKS
Credential	:
Telephone Number	:	702-272-9079

Provider Enumeration Date	:	06/14/2018
Last Update Date	:	06/14/2018

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