MEDICARE: AGAPE WELLNESS AND FAMILY SERVICES

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	16140110	GA

General Provider Information

NPI Number	:	1306263967
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AGAPE WELLNESS AND FAMILY SERVICES

Provider Business Mailing Address
First Line	:	6112 RIVEROAK TER
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30349-4078
Country	:	US
Telephone Number	:	770-580-0960
Fax Number	:	702-974-1342

Provider Business Practice Location Address
First Line	:	7100 GRAND MONTECITO PKWY
Second Line	:	UNIT 3063
City	:	LAS VEGAS
State	:	NV
Zip	:	89149-0282
Country	:	US
Telephone Number	:	702-578-3035
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	BAILEY C MATTISON
Credential	:	BA
Telephone Number	:	702-578-3035

Provider Enumeration Date	:	03/20/2014
Last Update Date	:	03/20/2014

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