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General NPI Number Information
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NPI Number | 1245801273
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Entity Type | Organization
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Legal Business Name | MODERN WELLNESS CLINIC, LLC
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Dates
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Enumeration Date | 07/09/2021
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Last Update Date | 06/12/2025
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Provider Practice Location Address
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Address Line | 5375 S FORT APACHE RD
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City | LAS VEGAS
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State | NV
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Zip | 89148-7623
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Country | US
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Telephone | 702-463-9159
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Fax |
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Provider Business Mailing Address
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Address Line | 5375 S FORT APACHE RD
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City | LAS VEGAS
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State | NV
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Zip | 89148-7623
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MANAGING PARNER
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Name | ROBERT J WEBB
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Credential | PA
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Telephone | 702-236-7171
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RI0200X
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Taxonomy Name | Infectious Disease Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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