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General NPI Number Information
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NPI Number | 1194685479
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Entity Type | Organization
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Legal Business Name | PRIMA RESTORATIVE AND WELLNESS
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Dates
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Enumeration Date | 11/18/2025
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Last Update Date | 11/18/2025
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Provider Practice Location Address
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Address Line | 309 W BROADWAY
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City | GLENDALE
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State | CA
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Zip | 91204-1301
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Country | US
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Telephone | 310-993-9691
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Fax |
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Provider Business Mailing Address
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Address Line | 309 W BROADWAY
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City | GLENDALE
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State | CA
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Zip | 91204-1301
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | ANTHONY RYAN MIGUEL AGUIRRE
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Credential | MD
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Telephone | 310-993-9691
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QG0300X
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Taxonomy Name | Geriatric Medicine (Family Medicine) Physician
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License Number |
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License Number State |
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