Healthcare Provider Details

I. General information

NPI: 1366820961
Provider Name (Legal Business Name): SEA BREEZE WELLNESS CENTER LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2015
Last Update Date: 05/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2021 S JONES BLVD
LAS VEGAS NV
89146-3137
US

IV. Provider business mailing address

2021 S JONES BLVD
LAS VEGAS NV
89146-3137
US

V. Phone/Fax

Practice location:
  • Phone: 702-202-0099
  • Fax: 702-778-7632
Mailing address:
  • Phone: 702-202-0099
  • Fax: 702-778-7632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number20150212685-92
License Number StateNV

VIII. Authorized Official

Name: DR. MATTHEW O OKEKE
Title or Position: PRESIDENT
Credential: MD
Phone: 702-202-0099