Healthcare Provider Details

I. General information

NPI: 1821642059
Provider Name (Legal Business Name): COMMUNITY WELLNESS MEDICAL CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2019
Last Update Date: 08/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1218 S INGLEWOOD AVE
INGLEWOOD CA
90301-3649
US

IV. Provider business mailing address

1458 E GLADWICK ST
CARSON CA
90746-3804
US

V. Phone/Fax

Practice location:
  • Phone: 310-722-5146
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: ROSE N EKEJIUBA
Title or Position: OWNER
Credential: NP
Phone: 310-722-5146