MEDICARE: ABSOLUTE WELLNESS 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	251S00000X	Community/Behavioral Health Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1215408414
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ABSOLUTE WELLNESS CENTER LLC

Provider Business Mailing Address
First Line	:	708 COWBOY CROSS AVE
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89081-6746
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	708 COWBOY CROSS AVE
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89081-6746
Country	:	US
Telephone Number	:	702-337-8991
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	BRANDY MCCULLOUCH
Credential	:
Telephone Number	:	702-337-8991

Provider Enumeration Date	:	12/16/2018
Last Update Date	:	12/16/2018

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