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General NPI Number Information
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NPI Number | 1972874303
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Entity Type | Organization
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Legal Business Name | WELLNESS DIAGNOSTICS
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Dates
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Enumeration Date | 01/17/2012
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Last Update Date | 01/17/2012
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Provider Practice Location Address
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Address Line | 854 EMERALD BAY RD STE C
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City | SOUTH LAKE TAHOE
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State | CA
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Zip | 96150-6438
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Country | US
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Telephone | 530-544-2020
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Fax |
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Provider Business Mailing Address
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Address Line | 854 EMERALD BAY RD STE C
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City | SOUTH LAKE TAHOE
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State | CA
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Zip | 96150-6438
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Country | US
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Telephone | 530-544-2020
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Fax |
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Authorized Official
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Title or Position | CFO
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Name | DAVID SMITH
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Credential |
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Telephone | 904-791-6471
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | K11111
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License Number State | CA
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