Healthcare Provider Details

I. General information

NPI: 1033095914
Provider Name (Legal Business Name): GREATER GOOD HEALTH PC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2025
Last Update Date: 08/14/2025
Certification Date: 08/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3017 EAGLE DRIVE
AMMON ID
83406
US

IV. Provider business mailing address

300 CONTINENTAL BLVD STE 560
EL SEGUNDO CA
90245-5030
US

V. Phone/Fax

Practice location:
  • Phone: 626-232-3929
  • Fax:
Mailing address:
  • Phone: 626-232-3929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: SYLVIA HASTANAN
Title or Position: VICE PRESIDENT
Credential:
Phone: 310-795-8807