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General NPI Number Information
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NPI Number | 1104193192
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Entity Type | Organization
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Legal Business Name | GOOGLE WELLNESS CENTER, 321
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Dates
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Enumeration Date | 11/19/2011
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Last Update Date | 11/19/2011
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Provider Practice Location Address
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Address Line | 321 HAMPTON DR
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City | VENICE
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State | CA
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Zip | 90291-2696
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Country | US
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Telephone | 650-214-6369
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Fax | 650-253-2302
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Provider Business Mailing Address
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Address Line | 321 HAMPTON DR.
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City | VENICE
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State | CA
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Zip | 90291
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Country | US
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Telephone | 650-214-6369
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Fax | 650-253-2302
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Authorized Official
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Title or Position | MANAGER
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Name | DAVID LEES
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Credential |
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Telephone | 408-348-4214
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332900000X
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Taxonomy Name | Non-Pharmacy Dispensing Site
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License Number | A 73520
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License Number State | CA
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