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General NPI Number Information
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NPI Number | 1083457154
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Entity Type | Organization
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Legal Business Name | CORDILLERA WELLNESS COLLECTIVE INC
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Dates
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Enumeration Date | 06/17/2024
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Last Update Date | 06/17/2024
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Provider Practice Location Address
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Address Line | 2455 JEFFERSON BLVD STE 100
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City | WEST SACRAMENTO
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State | CA
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Zip | 95691-5329
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Country | US
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Telephone | 484-280-8349
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Fax |
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Provider Business Mailing Address
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Address Line | 3324 SAN SALVADOR ST
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City | WEST SACRAMENTO
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State | CA
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Zip | 95691-5925
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Country | US
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Telephone | 484-280-8349
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Fax |
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Authorized Official
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Title or Position | PROVIDER / MANAGER
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Name | JOCELYN A JARICK
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Credential | PA-C
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Telephone | 484-280-8349
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 202D00000X
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Taxonomy Name | Integrative Medicine Physician
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License Number |
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License Number State |
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