MEDICARE: RENEWED MIND WELLNESS CENTER

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	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1275069247
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RENEWED MIND WELLNESS CENTER

Provider Business Mailing Address
First Line	:	820 S 7TH ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89101-6938
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	117 ROSA ROSALES CT
Second Line	:
City	:	N LAS VEGAS
State	:	NV
Zip	:	89031-2593
Country	:	US
Telephone Number	:	702-497-6187
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	CHRISTOPHER OMOBHIO USIGBE
Credential	:
Telephone Number	:	702-497-6187

Provider Enumeration Date	:	05/11/2017
Last Update Date	:	05/11/2017

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