Healthcare Provider Details

I. General information

NPI: 1932300944
Provider Name (Legal Business Name): WEST COAST ENDOCRINE A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 01/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 E ATHERTON ST SUITE 416
LONG BEACH CA
90815-4016
US

IV. Provider business mailing address

5500 E ATHERTON ST SUITE 416
LONG BEACH CA
90815-4016
US

V. Phone/Fax

Practice location:
  • Phone: 562-988-0040
  • Fax: 562-988-0041
Mailing address:
  • Phone: 562-988-0040
  • Fax: 562-988-0041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberW17025
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberW17025
License Number StateCA

VIII. Authorized Official

Name: JENNIFER CONNELLY
Title or Position: OWNER
Credential: DO
Phone: 562-988-0040