Healthcare Provider Details

I. General information

NPI: 1760952576
Provider Name (Legal Business Name): WOMENS CENTER FOR PELVIC WELLNESS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2018
Last Update Date: 05/18/2020
Certification Date: 05/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

542 S FAIR OAKS AVE FL 2
PASADENA CA
91105
US

IV. Provider business mailing address

PO BOX 24682
BELFAST ME
04915-4497
US

V. Phone/Fax

Practice location:
  • Phone: 626-535-0832
  • Fax: 626-535-0842
Mailing address:
  • Phone: 626-535-0832
  • Fax: 626-535-0842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number
License Number State

VIII. Authorized Official

Name: DAVID M KIMBLE
Title or Position: OWNER
Credential: MD
Phone: 626-535-0832