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General NPI Number Information
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NPI Number | 1639824105
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Entity Type | Organization
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Legal Business Name | WONDERMED OF CALIFORNIA, INC
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Dates
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Enumeration Date | 02/14/2022
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Last Update Date | 03/28/2022
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Provider Practice Location Address
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Address Line | 828 CRESTMOORE PL
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City | VENICE
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State | CA
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Zip | 90291-4931
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Country | US
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Telephone | 310-692-1469
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Fax |
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Provider Business Mailing Address
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Address Line | 828 CRESTMOORE PL
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City | VENICE
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State | CA
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Zip | 90291-4931
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Country | US
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Telephone | 310-692-1469
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Fax |
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Authorized Official
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Title or Position | COMPLIANCE
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Name | SANTINO LABATE
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Credential |
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Telephone | 949-201-6090
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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