=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235843723
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GLUTALITY PROVIDER GROUP OF CALIFORNIA PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/09/2023
-----------------------------------------------------
Last Update Date | 07/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7250 REDWOOD BLVD STE 300
-----------------------------------------------------
City | NOVATO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94945-3269
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-678-2026
-----------------------------------------------------
Fax | 561-423-9249
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 401 FAIRWAY DR STE 200
-----------------------------------------------------
City | DEERFIELD BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33441-1800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-678-2026
-----------------------------------------------------
Fax | 561-423-9249
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MITCHELL STOTTLAND
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 561-678-2026
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------