=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992034789
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WATERMAN HEALTH INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/08/2009
-----------------------------------------------------
Last Update Date | 12/08/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1396 N WATERMAN AVE 109
-----------------------------------------------------
City | SAN BERNARDINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92404-5313
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-885-2464
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1396 N WATERMAN 109
-----------------------------------------------------
City | SAN BERNARDION
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92404-5313
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-885-2464
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. MIKE VISOVSKI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 909-885-2464
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------