Healthcare Provider Details

I. General information

NPI: 1821539511
Provider Name (Legal Business Name): ALTA WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2017
Last Update Date: 03/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

153 W LAKE MEAD PKWY STE 3110
HENDERSON NV
89015-8006
US

IV. Provider business mailing address

1027 S RAINBOW BLVD # 270
LAS VEGAS NV
89145-6232
US

V. Phone/Fax

Practice location:
  • Phone: 702-365-0060
  • Fax: 702-365-0602
Mailing address:
  • Phone: 702-365-0060
  • Fax: 702-365-0602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: ROBERTO SUAREZ
Title or Position: OWNER
Credential:
Phone: 702-365-0600