Healthcare Provider Details

I. General information

NPI: 1790586576
Provider Name (Legal Business Name): WHOLE FITNESS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2025
Last Update Date: 09/11/2025
Certification Date: 03/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17982 LUCERO WAY
TUSTIN CA
92780-2624
US

IV. Provider business mailing address

17982 LUCERO WAY
TUSTIN CA
92780-2624
US

V. Phone/Fax

Practice location:
  • Phone: 808-987-1151
  • Fax:
Mailing address:
  • Phone: 808-987-1151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL R RUSSO
Title or Position: CEO
Credential: MS, CPSS
Phone: 808-987-1511