Healthcare Provider Details

I. General information

NPI: 1700417797
Provider Name (Legal Business Name): BROADWAY WELLNESS CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2020
Last Update Date: 03/23/2021
Certification Date: 03/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 ARDEN AVE SUITE 520
GLENDALE CA
91203
US

IV. Provider business mailing address

435 ARDEN AVE SUITE 520
GLENDALE CA
91203
US

V. Phone/Fax

Practice location:
  • Phone: 818-696-0091
  • Fax: 818-484-2449
Mailing address:
  • Phone: 818-696-0091
  • Fax: 818-484-2449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: SILVA MORADI
Title or Position: CEO
Credential:
Phone: 818-696-0091