Healthcare Provider Details

I. General information

NPI: 1265623110
Provider Name (Legal Business Name): MT DIABLO INTEGRATED WELLNESS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2007
Last Update Date: 02/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 N WIGET LN SUITE 130
WALNUT CREEK CA
94598-2435
US

IV. Provider business mailing address

325 N WIGET LN SUITE 130
WALNUT CREEK CA
94598-2435
US

V. Phone/Fax

Practice location:
  • Phone: 925-935-5425
  • Fax: 925-947-2671
Mailing address:
  • Phone: 925-935-5425
  • Fax: 925-947-2671

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA67699
License Number StateCA

VIII. Authorized Official

Name: DR. SUPRABHA N JAIN
Title or Position: OWNER
Credential: M.D
Phone: 925-935-5425