Healthcare Provider Details

I. General information

NPI: 1356250328
Provider Name (Legal Business Name): ELITE WELLNESS SCIENCES, LLC DBA DOMINATE YOUR GAME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2026
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6171 MCLEOD DR STE A
LAS VEGAS NV
89120-4410
US

IV. Provider business mailing address

6171 MCLEOD DR STE A
LAS VEGAS NV
89120-4410
US

V. Phone/Fax

Practice location:
  • Phone: 702-567-3495
  • Fax:
Mailing address:
  • Phone: 702-567-3495
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number StateNULL

VIII. Authorized Official

Name: LACY M PUTTUCK
Title or Position: DIRECTOR
Credential: RDN
Phone: 702-567-3495