Healthcare Provider Details

I. General information

NPI: 1467796474
Provider Name (Legal Business Name): BLACK WOMEN FOR WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2012
Last Update Date: 11/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4340 11TH AVE
LOS ANGELES CA
90008-5205
US

IV. Provider business mailing address

PO BOX 292516
LOS ANGELES CA
90029-7516
US

V. Phone/Fax

Practice location:
  • Phone: 323-290-5955
  • Fax:
Mailing address:
  • Phone: 323-290-5955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number StateCA

VIII. Authorized Official

Name: MS. JANETTE ROBINSON FLINT
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 323-290-5955