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General NPI Number Information
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NPI Number | 1629345590
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Entity Type | Organization
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Legal Business Name | GLOBAL NUTRACEUTICALS, INC
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Dates
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Enumeration Date | 11/21/2011
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Last Update Date | 11/21/2011
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Provider Practice Location Address
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Address Line | 140 AVENIDA ALGODON UNIT B
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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 | 949-366-0432
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Fax | 949-542-7020
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Provider Business Mailing Address
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Address Line | 140 AVENIDA ALGODON UNIT B
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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 | 949-366-0432
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Fax | 949-542-7020
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Authorized Official
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Title or Position | OWNER
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Name | DR. WILLA LILLY
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Credential | DO
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Telephone | 949-366-0432
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number | 20A4676
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License Number State | CA
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