Healthcare Provider Details

I. General information

NPI: 1124478185
Provider Name (Legal Business Name): WELLNESS WAVE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2016
Last Update Date: 06/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 N ROXBURY DR
BEVERLY HILLS CA
90210-5001
US

IV. Provider business mailing address

455 N ROXBURY DR
BEVERLY HILLS CA
90210-5001
US

V. Phone/Fax

Practice location:
  • Phone: 310-920-0991
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number StateCA

VIII. Authorized Official

Name: LIZA VISMANOS
Title or Position: PRESIDENT
Credential:
Phone: 310-920-0991