MEDICARE: WHOLISTIC RECOVERY CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1093485336
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WHOLISTIC RECOVERY CENTER LLC

Provider Business Mailing Address
First Line	:	2580 N RANCHO DR STE 105
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89130-3361
Country	:	US
Telephone Number	:	702-981-0289
Fax Number	:

Provider Business Practice Location Address
First Line	:	2580 N RANCHO DR STE 105
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89130-3361
Country	:	US
Telephone Number	:	702-981-0289
Fax Number	:

Authorized Official
Title or Position	:	THERAPIST
Name	:	MS. LUCIA CAROL MATTHEW
Credential	:	CPC-INTERN
Telephone Number	:	707-981-0289

Provider Enumeration Date	:	09/17/2021
Last Update Date	:	09/17/2021

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