Healthcare Provider Details

I. General information

NPI: 1447773825
Provider Name (Legal Business Name): 360 WELLNESS SOLUTIONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2017
Last Update Date: 08/24/2022
Certification Date: 08/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

194 LOCH LOMOND RD
RANCHO MIRAGE CA
92270-5600
US

IV. Provider business mailing address

194 LOCH LOMOND RD
RANCHO MIRAGE CA
92270-5600
US

V. Phone/Fax

Practice location:
  • Phone: 760-832-8025
  • Fax: 760-764-4010
Mailing address:
  • Phone: 760-832-8025
  • Fax: 760-764-4010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KATHERINE JOSEPHINE SULLIVAN
Title or Position: PRESIDENT
Credential: PHD, PT
Phone: 760-832-8025