Healthcare Provider Details

I. General information

NPI: 1326445768
Provider Name (Legal Business Name): WHOLE LIFE BALANCE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2014
Last Update Date: 12/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7171 MACAPA DR
LOS ANGELES CA
90068-2003
US

IV. Provider business mailing address

7171 MACAPA DR
LOS ANGELES CA
90068-2003
US

V. Phone/Fax

Practice location:
  • Phone: 310-348-0500
  • Fax: 310-348-0201
Mailing address:
  • Phone: 310-348-0500
  • Fax: 310-348-0201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number999999999
License Number StateCA

VIII. Authorized Official

Name: SHANE GRIFFIN
Title or Position: PRESIDENT
Credential: CNP
Phone: 310-348-0500