=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083296511
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALTHCARE & WELLNESS ASSOCIATES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2021
-----------------------------------------------------
Last Update Date | 04/23/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3430 E FLAMINGO RD STE 200
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89121-5064
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-478-4507
-----------------------------------------------------
Fax | 702-478-4805
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5070 PENRYN CT
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89139-7059
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-401-4749
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | MARIE MATTA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 702-401-4749
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------