Healthcare Provider Details

I. General information

NPI: 1457954224
Provider Name (Legal Business Name): CORPORATE PARK WELLNESS CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2020
Last Update Date: 11/16/2020
Certification Date: 11/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43 CORPORATE PARK STE 204
IRVINE CA
92606-5137
US

IV. Provider business mailing address

43 CORPORATE PARK STE 204
IRVINE CA
92606-5137
US

V. Phone/Fax

Practice location:
  • Phone: 714-550-0788
  • Fax: 714-550-6001
Mailing address:
  • Phone: 714-550-0788
  • Fax: 714-550-6001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: JEFF ALLEN FISHER
Title or Position: PARTNER AND SHARE HOLDER
Credential: DC
Phone: 714-550-0788