MEDICARE: SENIOR WELLNESS DYNAMICS, LLC

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	103TB0200X	Cognitive & Behavioral Psychologist

General Provider Information

NPI Number	:	1780050674
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SENIOR WELLNESS DYNAMICS, LLC

Provider Business Mailing Address
First Line	:	PO BOX 9961
Second Line	:
City	:	REDLANDS
State	:	CA
Zip	:	92375-3161
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	183 ORANGE PARK
Second Line	:
City	:	REDLANDS
State	:	CA
Zip	:	92374-5543
Country	:	US
Telephone Number	:	909-965-1877
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	MR. TONY RIOS
Credential	:
Telephone Number	:	909-965-1877

Provider Enumeration Date	:	08/14/2015
Last Update Date	:	08/14/2015

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