Healthcare Provider Details

I. General information

NPI: 1235677477
Provider Name (Legal Business Name): 1 LOVE WELLNESS SOCIETY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2017
Last Update Date: 09/03/2021
Certification Date: 09/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5940 S RAINBOW BLVD STE 213 RM 1014
LAS VEGAS NV
89118-2506
US

IV. Provider business mailing address

5940 S RAINBOW BLVD STE 213 RM 1014
LAS VEGAS NV
89118-2506
US

V. Phone/Fax

Practice location:
  • Phone: 562-714-2146
  • Fax:
Mailing address:
  • Phone: 562-714-2146
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberNV20161704135
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberNV20161704135
License Number StateNV

VIII. Authorized Official

Name: DENISE MADISON
Title or Position: OWNER
Credential:
Phone: 562-714-2146