MEDICARE: GOLD WELLNESS INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	25860	CA

General Provider Information

NPI Number	:	1053311332
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOLD WELLNESS INC

Provider Business Mailing Address
First Line	:	6221 WILSHIRE BLVD.,
Second Line	:	#616
City	:	LOS ANGELES
State	:	CA
Zip	:	90048
Country	:	US
Telephone Number	:	323-939-7050
Fax Number	:	323-939-7056

Provider Business Practice Location Address
First Line	:	6221 WILSHIRE BLVD
Second Line	:	#616
City	:	LOS ANGELES
State	:	CA
Zip	:	90048-5201
Country	:	US
Telephone Number	:	323-939-7050
Fax Number	:	323-939-7056

Authorized Official
Title or Position	:	CEO
Name	:	MR. VADIM GOLD
Credential	:	PT
Telephone Number	:	323-939-7050

Provider Enumeration Date	:	07/28/2005
Last Update Date	:	04/04/2008

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Directions to “GOLD WELLNESS INC ” Practice Location

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