Healthcare Provider Details

I. General information

NPI: 1619668498
Provider Name (Legal Business Name): THE INDI WOMENS CLUB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2023
Last Update Date: 05/15/2023
Certification Date: 05/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2825 CAPITOL AVE
SACRAMENTO CA
95816-6039
US

IV. Provider business mailing address

5960 S LAND PARK DR # 1409
SACRAMENTO CA
95822-3313
US

V. Phone/Fax

Practice location:
  • Phone: 510-768-8433
  • Fax:
Mailing address:
  • Phone: 510-768-8433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateNULL

VIII. Authorized Official

Name: NIKKIA PATTERSON
Title or Position: CEO
Credential: BSN, MCD
Phone: 614-817-4160