MEDICARE: MIND HEART AND SOUL BEHAVIOR COUNSELING & WELLNESS GROUP

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	302R00000X	Health Maintenance Organization	251500000X	NV

General Provider Information

NPI Number	:	1376957886
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIND HEART AND SOUL BEHAVIOR COUNSELING & WELLNESS GROUP

Provider Business Mailing Address
First Line	:	1410 SANTA MARGARITA ST
Second Line	:	UNIT H
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-2939
Country	:	US
Telephone Number	:	702-477-5086
Fax Number	:

Provider Business Practice Location Address
First Line	:	1410 SANTA MARGARITA ST
Second Line	:	UNIT H
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-2939
Country	:	US
Telephone Number	:	702-477-5086
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	CEDRA PERRY
Credential	:
Telephone Number	:	702-477-5086

Provider Enumeration Date	:	06/12/2014
Last Update Date	:	06/12/2014

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