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General NPI Number Information
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NPI Number | 1306263967
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Entity Type | Organization
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Legal Business Name | AGAPE WELLNESS AND FAMILY SERVICES
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Dates
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Enumeration Date | 03/20/2014
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Last Update Date | 03/20/2014
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Provider Practice Location Address
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Address Line | 7100 GRAND MONTECITO PKWY UNIT 3063
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City | LAS VEGAS
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State | NV
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Zip | 89149-0282
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Country | US
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Telephone | 702-578-3035
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Fax |
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Provider Business Mailing Address
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Address Line | 6112 RIVEROAK TER
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City | ATLANTA
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State | GA
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Zip | 30349-4078
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Country | US
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Telephone | 770-580-0960
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Fax | 702-974-1342
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Authorized Official
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Title or Position | CEO
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Name | BAILEY C MATTISON
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Credential | BA
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Telephone | 702-578-3035
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 16140110
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License Number State | GA
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