Healthcare Provider Details

I. General information

NPI: 1932330867
Provider Name (Legal Business Name): OREST V PETRISHEN N.D., PH.D., C.N.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2009
Last Update Date: 05/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6333 WILSHIRE BLVD STE #200
LOS ANGELES CA
90048-5702
US

IV. Provider business mailing address

6333 WILSHIRE BLVD STE #200
LOS ANGELES CA
90048-5702
US

V. Phone/Fax

Practice location:
  • Phone: 323-653-2504
  • Fax: 323-653-2515
Mailing address:
  • Phone: 323-382-4211
  • Fax: 323-654-5373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberCNC-2372
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code175F00000X
TaxonomyNaturopath
License NumberNAT-375
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: