Healthcare Provider Details

I. General information

NPI: 1376205666
Provider Name (Legal Business Name): HEAL YOUR BODY & MIND MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2021
Last Update Date: 04/06/2022
Certification Date: 04/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9924 TAMARACK LANDING WAY
LAS VEGAS NV
89117-0913
US

IV. Provider business mailing address

9924 TAMARACK LANDING WAY
LAS VEGAS NV
89117-0913
US

V. Phone/Fax

Practice location:
  • Phone: 702-742-5972
  • Fax:
Mailing address:
  • Phone: 702-742-5972
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARIA ELIZABETH PUENTES
Title or Position: CEO
Credential:
Phone: 702-742-5972