Provider Demographics
NPI:1578118717
Name:VEGAS WELLNESS TREATMENT CENTER
Entity Type:Organization
Organization Name:VEGAS WELLNESS TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:IBIRONKE
Authorized Official - Middle Name:
Authorized Official - Last Name:ALAGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-822-0447
Mailing Address - Street 1:3920 W CHARLESTON BLVD STE N
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-1651
Mailing Address - Country:US
Mailing Address - Phone:702-478-2819
Mailing Address - Fax:
Practice Address - Street 1:3920 W CHARLESTON BLVD STE N
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-1651
Practice Address - Country:US
Practice Address - Phone:702-478-5541
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VEGAS WELLNESS TREATMENT CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-08-05
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV786005Medicaid