Healthcare Provider Details

I. General information

NPI: 1013501261
Provider Name (Legal Business Name): HEALTHY LIFESTYLE CONSULTANT AND COACH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2021
Last Update Date: 02/26/2021
Certification Date: 02/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2951 HAMPSHIRE CIR
CORONA CA
92879-6133
US

IV. Provider business mailing address

PO BOX 17958
IRVINE CA
92623-7958
US

V. Phone/Fax

Practice location:
  • Phone: 951-268-6924
  • Fax: 951-268-6924
Mailing address:
  • Phone: 951-268-6924
  • Fax: 951-268-6924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number State

VIII. Authorized Official

Name: DR. JOANA A TALA
Title or Position: OWNER/MANAGER
Credential: MD, DIPACLM
Phone: 951-268-6924