MEDICARE: NEURO WELLNESS SPA, A MEDICAL PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	G78080	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1811442767	OTHER	CA	NPPES
2	1497899728	OTHER	CA	NPPES

General Provider Information

NPI Number	:	1003394149
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEURO WELLNESS SPA, A MEDICAL PC

Provider Business Mailing Address
First Line	:	1101 N SEPULVEDA BLVD STE 201
Second Line	:
City	:	MANHATTAN BEACH
State	:	CA
Zip	:	90266-5963
Country	:	US
Telephone Number	:	310-545-4450
Fax Number	:	310-564-2295

Provider Business Practice Location Address
First Line	:	1101 N SEPULVEDA BLVD STE 201
Second Line	:
City	:	MANHATTAN BEACH
State	:	CA
Zip	:	90266-5963
Country	:	US
Telephone Number	:	310-545-4450
Fax Number	:	310-564-2295

Authorized Official
Title or Position	:	DIRECTOR OF OPERATIONS
Name	:	SCOTT DOHREN
Credential	:
Telephone Number	:	858-735-2472

Provider Enumeration Date	:	07/31/2018
Last Update Date	:	06/11/2019

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