Healthcare Provider Details

I. General information

NPI: 1255214250
Provider Name (Legal Business Name): FUNDAMENTALS FITNESS & MENTAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2025
Last Update Date: 07/28/2025
Certification Date: 07/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3955 EAST OWENS AVE SUITE 120-130
LAS VEGAS NV
89110
US

IV. Provider business mailing address

304 S JONES BLVD # 7716
LAS VEGAS NV
89107-2623
US

V. Phone/Fax

Practice location:
  • Phone: 909-754-3952
  • Fax:
Mailing address:
  • Phone: 909-754-3952
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MELINA SANCHEZ MARTINEZ
Title or Position: LICENSE CLINICAL SOCIAL WORKER,CEO
Credential: LCSW
Phone: 909-754-3952