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General NPI Number Information
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NPI Number | 1104503168
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Entity Type | Organization
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Legal Business Name | GREATER GOOD HEALTH PC, INC.
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Dates
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Enumeration Date | 06/30/2023
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Last Update Date | 10/31/2023
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Provider Practice Location Address
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Address Line | 2230 N RESERVE ST STE 110
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City | MISSOULA
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State | MT
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Zip | 59808-1364
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Country | US
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Telephone | 310-658-3775
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Fax |
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Provider Business Mailing Address
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Address Line | 300 CONTINENTAL BLVD STE 635
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City | EL SEGUNDO
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State | CA
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Zip | 90245-5040
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Country | US
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Telephone | 310-658-3775
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Fax |
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Authorized Official
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Title or Position | VICE PRESIDENT
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Name | SYLVIA HASTANAN
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Credential |
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Telephone | 310-795-8807
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP2300X
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Taxonomy Name | Primary Care Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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