Healthcare Provider Details

I. General information

NPI: 1669852968
Provider Name (Legal Business Name): THE WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2015
Last Update Date: 06/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 HIGHLAND AVE
SMITH RIVER CA
95567-9519
US

IV. Provider business mailing address

415 HIGHLAND AVE
SMITH RIVER CA
95567-9519
US

V. Phone/Fax

Practice location:
  • Phone: 707-487-4444
  • Fax:
Mailing address:
  • Phone: 707-487-4444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC7529
License Number StateCA

VIII. Authorized Official

Name: MS. JODY LYNN MANGUM
Title or Position: LICENSED ACUPUNCTURIST/ OWNER
Credential: MSOM
Phone: 707-487-4444