=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982303079
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALTHY MEDICAL WELLNESS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2023
-----------------------------------------------------
Last Update Date | 02/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4193 FLAT ROCK DR STE 200
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92505-7113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-208-9377
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5120 HAMNER AVE STE 140 #568
-----------------------------------------------------
City | EASTVALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91752
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-208-9377
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | BRANDY LIU
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 626-208-9377
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------