Provider Demographics
NPI:1568956498
Name:ETERNITY HEALTH WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:ETERNITY HEALTH WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LACONJA
Authorized Official - Middle Name:
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-272-9079
Mailing Address - Street 1:6332 LEGEND FALLS ST
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89081-6621
Mailing Address - Country:US
Mailing Address - Phone:702-272-9079
Mailing Address - Fax:
Practice Address - Street 1:6332 LEGEND FALLS ST
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89081-6621
Practice Address - Country:US
Practice Address - Phone:702-272-9079
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-14
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty