Provider Demographics
NPI:1730995929
Name:BODY MIND AND WELLNESS CLINIC INCORPORATED
Entity type:Organization
Organization Name:BODY MIND AND WELLNESS CLINIC INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:GIL
Authorized Official - Last Name:LLANES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-376-2485
Mailing Address - Street 1:2810 W CHARLESTON BLVD STE 57
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-1906
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2810 W CHARLESTON BLVD STE 57
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-1906
Practice Address - Country:US
Practice Address - Phone:702-376-2485
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-04
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty