Healthcare Provider Details

I. General information

NPI: 1164466884
Provider Name (Legal Business Name): NOURISHING WELLNESS MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 04/20/2020
Certification Date: 04/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

819 N HARBOR DR STE 310
REDONDO BEACH CA
90277-2056
US

IV. Provider business mailing address

819 N HARBOR DR STE 310
REDONDO BEACH CA
90277-2056
US

V. Phone/Fax

Practice location:
  • Phone: 310-373-7830
  • Fax: 310-373-7830
Mailing address:
  • Phone: 310-373-7830
  • Fax: 310-373-7840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ALLEN HERMANN PETERS
Title or Position: PRESIDENT/MEDICAL DIRECTOR
Credential: M.D.
Phone: 310-373-7830