Healthcare Provider Details

I. General information

NPI: 1750777983
Provider Name (Legal Business Name): THEWELL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2015
Last Update Date: 04/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1485 E FLAMINGO RD
LAS VEGAS NV
89119-5256
US

IV. Provider business mailing address

1485 E FLAMINGO RD
LAS VEGAS NV
89119-5256
US

V. Phone/Fax

Practice location:
  • Phone: 844-282-9355
  • Fax: 702-386-0977
Mailing address:
  • Phone: 844-282-9355
  • Fax: 702-386-0977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN001599
License Number StateNV

VIII. Authorized Official

Name: DANIEL GATH
Title or Position: MSO
Credential:
Phone: 844-282-9355