MEDICARE: BODY MIND AND WELLNESS CLINIC INCORPORATED

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	2084P0800X	Psychiatry Physician
2	363LF0000X	Family Nurse Practitioner
3	363LP0808X	Psychiatric/Mental Health Nurse Practitioner
4	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1730995929
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BODY MIND AND WELLNESS CLINIC INCORPORATED

Provider Business Mailing Address
First Line	:	2810 W CHARLESTON BLVD STE 57
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89102-1906
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2810 W CHARLESTON BLVD STE 57
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89102-1906
Country	:	US
Telephone Number	:	702-376-2485
Fax Number	:

Authorized Official
Title or Position	:	OWNER AND DIRECTOR
Name	:	IVAN GIL LLANES
Credential	:
Telephone Number	:	702-376-2485

Provider Enumeration Date	:	12/04/2024
Last Update Date	:	12/04/2024

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