Healthcare Provider Details

I. General information

NPI: 1659871176
Provider Name (Legal Business Name): WINDHAM INTEGRATIVE MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2018
Last Update Date: 02/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 BIRCH ST STE 3000
NEWPORT BEACH CA
92660-2140
US

IV. Provider business mailing address

6400 INDUSTRIAL LOOP
GREENDALE WI
53129-2452
US

V. Phone/Fax

Practice location:
  • Phone: 714-955-1508
  • Fax:
Mailing address:
  • Phone: 414-858-4106
  • Fax: 414-423-4134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DEANNA C WINDHAM
Title or Position: PRESIDENT
Credential: DO
Phone: 714-955-1508