Healthcare Provider Details

I. General information

NPI: 1245801273
Provider Name (Legal Business Name): MODERN WELLNESS CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2021
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5375 S FORT APACHE RD
LAS VEGAS NV
89148-7623
US

IV. Provider business mailing address

5375 S FORT APACHE RD
LAS VEGAS NV
89148-7623
US

V. Phone/Fax

Practice location:
  • Phone: 702-463-9159
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBERT J WEBB
Title or Position: MANAGING PARNER
Credential: PA
Phone: 702-236-7171