MEDICARE: INDIGO WELLNESS

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)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1871158089
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDIGO WELLNESS

Provider Business Mailing Address
First Line	:	4309 SNEAD DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89107-2070
Country	:	US
Telephone Number	:	702-913-3663
Fax Number	:

Provider Business Practice Location Address
First Line	:	4309 SNEAD DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89107-2070
Country	:	US
Telephone Number	:	702-913-3663
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JAMES CARTER
Credential	:
Telephone Number	:	702-913-3663

Provider Enumeration Date	:	05/02/2019
Last Update Date	:	07/12/2019

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Directions to “INDIGO WELLNESS ” Practice Location

Language	Start Address	Practice Location

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