Healthcare Provider Details

I. General information

NPI: 1194685479
Provider Name (Legal Business Name): PRIMA RESTORATIVE AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2025
Last Update Date: 11/18/2025
Certification Date: 11/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 W BROADWAY
GLENDALE CA
91204-1301
US

IV. Provider business mailing address

309 W BROADWAY
GLENDALE CA
91204-1301
US

V. Phone/Fax

Practice location:
  • Phone: 310-993-9691
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: ANTHONY RYAN MIGUEL AGUIRRE
Title or Position: CEO
Credential: MD
Phone: 310-993-9691