Healthcare Provider Details

I. General information

NPI: 1386180222
Provider Name (Legal Business Name): HEART AND WELLNESS CENTER A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2017
Last Update Date: 01/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 EUCLID AVE SUITE #104
NATIONAL CITY CA
91950-2931
US

IV. Provider business mailing address

502 EUCLID AVE SUITE #104
NATIONAL CITY CA
91950-2931
US

V. Phone/Fax

Practice location:
  • Phone: 619-434-4288
  • Fax: 888-501-2443
Mailing address:
  • Phone: 619-434-4288
  • Fax: 888-501-2443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberC55986
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License NumberA76050
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberA124001
License Number StateCA

VIII. Authorized Official

Name: MARIUSZ W WYSOCZANSKI
Title or Position: CEO
Credential: M.D.
Phone: 619-434-4288