Healthcare Provider Details

I. General information

NPI: 1710533948
Provider Name (Legal Business Name): WELLNESS SOLUTION MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2019
Last Update Date: 09/22/2021
Certification Date: 09/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6719 GREENBUSH AVE
VALLEY GLEN CA
91401-1204
US

IV. Provider business mailing address

12115 MAGNOLIA BLVD # 14
N HOLLYWOOD CA
91607-2609
US

V. Phone/Fax

Practice location:
  • Phone: 818-487-1795
  • Fax:
Mailing address:
  • Phone: 818-487-1795
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: BRIAN KEITH GAMBLE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 818-487-1795