Healthcare Provider Details

I. General information

NPI: 1619704293
Provider Name (Legal Business Name): COMMUNITY VIRTUAL WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2024
Last Update Date: 02/25/2025
Certification Date: 02/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1208 CORRAL CREEK AVE APT 4
PASO ROBLES CA
93446-5013
US

IV. Provider business mailing address

1241 JOHNSON AVE # 316
SAN LUIS OBISPO CA
93401-3306
US

V. Phone/Fax

Practice location:
  • Phone: 404-790-0911
  • Fax:
Mailing address:
  • Phone: 404-790-0911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: YVONNE JONES-WICKS
Title or Position: OWNER
Credential: PHYSICIAN ASSOCIATE
Phone: 404-790-0911