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General NPI Number Information
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NPI Number | 1154627925
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Entity Type | Organization
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Legal Business Name | PHYSICIAN NUTRACEUTICAL RESEARCH, INC
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Dates
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Enumeration Date | 01/26/2011
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Last Update Date | 01/26/2011
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Provider Practice Location Address
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Address Line | 140 AVENIDA ALGODON #A, B & C
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City | SAN CLEMENTE
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State | CA
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Zip | 92672-4182
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Country | US
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Telephone | 888-508-3371
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Fax | 949-481-7063
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Provider Business Mailing Address
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Address Line | 140 AVENIDA ALGODON #A, B & C
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City | SAN CLEMENTE
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State | CA
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Zip | 92672-4182
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Country | US
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Telephone | 888-508-3371
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Fax | 949-481-7063
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | WILLA ANN LILLY
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Credential | D.O.
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Telephone | 888-508-3371
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number | 300189BP
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number | 300189CP
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number | 300189AP
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License Number State | CA
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