Healthcare Provider Details

I. General information

NPI: 1861639700
Provider Name (Legal Business Name): LIVE WELL NATUROPATHIC CLINIC, A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2009
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

78900 AVENUE 47 STE 102
LA QUINTA CA
92253-2070
US

IV. Provider business mailing address

78900 AVENUE 47 SUITE 102
LA QUINTA CA
92253-7168
US

V. Phone/Fax

Practice location:
  • Phone: 760-771-5970
  • Fax: 760-771-5982
Mailing address:
  • Phone: 760-771-5970
  • Fax: 760-771-5982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number331
License Number StateCA

VIII. Authorized Official

Name: DR. SONJA N FUNG
Title or Position: MEDICAL DIRECTOR
Credential: ND
Phone: 213-268-8884