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General NPI Number Information
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NPI Number | 1699123737
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Entity Type | Organization
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Legal Business Name | WELL MEDICAL, A PROFESSIONAL CORPORATION
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Dates
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Enumeration Date | 05/31/2016
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Last Update Date | 03/08/2021
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Provider Practice Location Address
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Address Line | 929 COLORADO AVE
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City | SANTA MONICA
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State | CA
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Zip | 90401-2716
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Country | US
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Telephone | 424-221-5012
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Fax |
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Provider Business Mailing Address
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Address Line | 2280 SAWTELLE BLVD. # 101
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City | LOS ANGELES
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State | CA
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Zip | 90064
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Country | US
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Telephone | 310-384-0970
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Fax |
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Authorized Official
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Title or Position | CHIEF OPERATING OFFICER
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Name | ILDAR FAZULYANOV
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Credential |
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Telephone | 310-384-0970
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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