Healthcare Provider Details

I. General information

NPI: 1487419057
Provider Name (Legal Business Name): OPTIMAL MENTAL HEALTH CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2024
Last Update Date: 02/23/2026
Certification Date: 02/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4760 S PECOS RD
LAS VEGAS NV
89121-6038
US

IV. Provider business mailing address

PO BOX 3055 SAINT ROSE PARKWAY
HENDERSON NV
89077
US

V. Phone/Fax

Practice location:
  • Phone: 725-200-1050
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MUNACHI EZENWATA
Title or Position: NURSE PRACTITIONER
Credential:
Phone: 725-200-1050