Healthcare Provider Details

I. General information

NPI: 1043059348
Provider Name (Legal Business Name): WELLNESS & EQUITY FOUNDATION INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2024
Last Update Date: 07/02/2024
Certification Date: 07/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

969 E 12TH ST STE D
LOS ANGELES CA
90021-2201
US

IV. Provider business mailing address

250 QUAIL RIDGE RD
SCOTTS VALLEY CA
95066-4821
US

V. Phone/Fax

Practice location:
  • Phone: 408-341-9606
  • Fax:
Mailing address:
  • Phone: 917-648-1068
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: WILLIAM RANDALL
Title or Position: MANAGER OF STRATEGIC INITIATIVES
Credential:
Phone: 913-548-5987