1760190136 NPI number — AMERICAN GRACE WELLNESS CENTER LLC

Table of content: (NPI 1760190136)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760190136 NPI number — AMERICAN GRACE WELLNESS CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AMERICAN GRACE WELLNESS CENTER LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1760190136
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3925 NORTH MARTIN LUTHER KING BLVD
Provider Second Line Business Mailing Address:
SUITE #212
Provider Business Mailing Address City Name:
NORTH LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89032-7673
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-444-2335
Provider Business Mailing Address Fax Number:
702-992-3505

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3925 NORTH MARTIN LUTHER KING BLVD
Provider Second Line Business Practice Location Address:
SUITE #212
Provider Business Practice Location Address City Name:
NORTH LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89032-7673
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-444-2335
Provider Business Practice Location Address Fax Number:
702-992-3505
Provider Enumeration Date:
11/14/2022

Additional Information

Authorized Official

Authorized Official Last Name:
GLASPER-SATTWHITE
Authorized Official First Name:
JACQUELINE
Authorized Official Middle Name:
B
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
702-444-0235

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9028-C . This is a "NEVADA SOCIAL WORK BOARD" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".




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