Healthcare Provider Details

I. General information

NPI: 1306263967
Provider Name (Legal Business Name): AGAPE WELLNESS AND FAMILY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2014
Last Update Date: 03/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7100 GRAND MONTECITO PKWY UNIT 3063
LAS VEGAS NV
89149-0282
US

IV. Provider business mailing address

6112 RIVEROAK TER
ATLANTA GA
30349-4078
US

V. Phone/Fax

Practice location:
  • Phone: 702-578-3035
  • Fax:
Mailing address:
  • Phone: 770-580-0960
  • Fax: 702-974-1342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number16140110
License Number StateGA

VIII. Authorized Official

Name: BAILEY C MATTISON
Title or Position: CEO
Credential: BA
Phone: 702-578-3035