Healthcare Provider Details

I. General information

NPI: 1932461902
Provider Name (Legal Business Name): DRMICHAELS WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2012
Last Update Date: 06/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

424 N LAKE AVE STE 102
PASADENA CA
91101-1202
US

IV. Provider business mailing address

424 N LAKE AVE STE 102
PASADENA CA
91101-1202
US

V. Phone/Fax

Practice location:
  • Phone: 626-440-7406
  • Fax:
Mailing address:
  • Phone: 626-440-7406
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License NumberCNS16073
License Number StateCA

VIII. Authorized Official

Name: DR. MARIOS MICHAEL I
Title or Position: DOCTOR
Credential: CNS
Phone: 626-440-7406