Healthcare Provider Details

I. General information

NPI: 1942086368
Provider Name (Legal Business Name): THE WELLNESS CENTER OF LAS VEGAS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2023
Last Update Date: 09/01/2023
Certification Date: 08/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 S DECATUR BLVD STE 415
LAS VEGAS NV
89107-2812
US

IV. Provider business mailing address

415 S DECATUR BLVD STE 415
LAS VEGAS NV
89107-2812
US

V. Phone/Fax

Practice location:
  • Phone: 702-462-2325
  • Fax:
Mailing address:
  • Phone: 702-462-2325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NANCY DIAGO
Title or Position: CEO
Credential: NP
Phone: 725-910-3725