Provider Demographics
NPI:1003394149
Name:NEURO WELLNESS SPA, A MEDICAL PC
Entity Type:Organization
Organization Name:NEURO WELLNESS SPA, A MEDICAL PC
Other - Org Name:NEURO WELLNESS SPA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:DOHREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-735-2472
Mailing Address - Street 1:1101 N SEPULVEDA BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-5963
Mailing Address - Country:US
Mailing Address - Phone:310-545-4450
Mailing Address - Fax:310-564-2295
Practice Address - Street 1:1101 N SEPULVEDA BLVD STE 201
Practice Address - Street 2:
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-5963
Practice Address - Country:US
Practice Address - Phone:310-545-4450
Practice Address - Fax:310-564-2295
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-31
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG780802084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1811442767OtherNPPES
CA1497899728OtherNPPES