Healthcare Provider Details

I. General information

NPI: 1730995929
Provider Name (Legal Business Name): BODY MIND AND WELLNESS CLINIC INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2024
Last Update Date: 12/04/2024
Certification Date: 12/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2810 W CHARLESTON BLVD STE 57
LAS VEGAS NV
89102-1906
US

IV. Provider business mailing address

2810 W CHARLESTON BLVD STE 57
LAS VEGAS NV
89102-1906
US

V. Phone/Fax

Practice location:
  • Phone: 702-376-2485
  • 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 Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: IVAN GIL LLANES
Title or Position: OWNER AND DIRECTOR
Credential:
Phone: 702-376-2485