Healthcare Provider Details

I. General information

NPI: 1306252986
Provider Name (Legal Business Name): EWELLNESS CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2014
Last Update Date: 07/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 3RD AVE
NEW YORK NY
10017-2803
US

IV. Provider business mailing address

322 CULVER BLVD # 217
PLAYA DEL REY CA
90293-7704
US

V. Phone/Fax

Practice location:
  • Phone: 310-915-6100
  • Fax:
Mailing address:
  • Phone: 310-915-6100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: DARWIN FOGT
Title or Position: CEO
Credential: MPT
Phone: 310-915-6100