Provider Demographics
NPI:1689426553
Name:PRIMEWELL SOLUTIONS BEHAVIORAL HEALTH
Entity Type:Organization
Organization Name:PRIMEWELL SOLUTIONS BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:DIAGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-350-8216
Mailing Address - Street 1:6385 BLACK SWAN LN
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89118-1998
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:421 S DECATUR BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89107-2812
Practice Address - Country:US
Practice Address - Phone:702-462-2325
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-03
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty