Healthcare Provider Details

I. General information

NPI: 1790595189
Provider Name (Legal Business Name): GLC WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2025
Last Update Date: 01/08/2025
Certification Date: 01/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 S 4TH ST STE 300
LAS VEGAS NV
89101-6206
US

IV. Provider business mailing address

PO BOX 3543
OAK BROOK IL
60522-3543
US

V. Phone/Fax

Practice location:
  • Phone: 877-767-1692
  • Fax:
Mailing address:
  • Phone: 877-767-1692
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateNULL

VIII. Authorized Official

Name: NANCY GRIFFIN
Title or Position: ADMINISTRATOR
Credential:
Phone: 312-730-4355