Provider Demographics
NPI:1275824195
Name:ONE HUNDRED PERCENT WELL LLC
Entity Type:Organization
Organization Name:ONE HUNDRED PERCENT WELL LLC
Other - Org Name:OPW
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:REESE
Authorized Official - Middle Name:LAMOUNTE
Authorized Official - Last Name:THOMAS-MCDADE
Authorized Official - Suffix:I
Authorized Official - Credentials:BSW
Authorized Official - Phone:702-275-5190
Mailing Address - Street 1:4559 SPARWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89147-8212
Mailing Address - Country:US
Mailing Address - Phone:702-275-5190
Mailing Address - Fax:702-430-1265
Practice Address - Street 1:2881 S VALLEY VIEW BLVD
Practice Address - Street 2:SUITE #25
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-0100
Practice Address - Country:US
Practice Address - Phone:702-275-5190
Practice Address - Fax:702-430-1265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-26
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV103K00000X103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty