Provider Demographics
NPI:1760190136
Name:AMERICAN GRACE WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:AMERICAN GRACE WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:B
Authorized Official - Last Name:GLASPER-SATTWHITE
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:702-444-0235
Mailing Address - Street 1:3925 NORTH MARTIN LUTHER KING BLVD
Mailing Address - Street 2:SUITE #212
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89032-7673
Mailing Address - Country:US
Mailing Address - Phone:702-444-2335
Mailing Address - Fax:702-992-3505
Practice Address - Street 1:3925 NORTH MARTIN LUTHER KING BLVD
Practice Address - Street 2:SUITE #212
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-7673
Practice Address - Country:US
Practice Address - Phone:702-444-2335
Practice Address - Fax:702-992-3505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-14
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV9028-COtherNEVADA SOCIAL WORK BOARD