Provider Demographics
NPI:1801657788
Name:WELLNESSREHAB PAIN MANAGEMENT CLINIC LLC
Entity type:Organization
Organization Name:WELLNESSREHAB PAIN MANAGEMENT CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:V
Authorized Official - Last Name:QUIBA
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, FNP-C
Authorized Official - Phone:702-576-6102
Mailing Address - Street 1:6720 N HUALAPAI WAY STE 145 BOX 312
Mailing Address - Street 2:BOX 312
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89149
Mailing Address - Country:US
Mailing Address - Phone:702-576-6102
Mailing Address - Fax:
Practice Address - Street 1:5120 S PECOS RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-1237
Practice Address - Country:US
Practice Address - Phone:702-720-4624
Practice Address - Fax:725-224-0909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-18
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPainGroup - Multi-Specialty
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty