Provider Demographics
NPI:1003685249
Name:MY GASTRO WELLNESS. LLC
Entity Type:Organization
Organization Name:MY GASTRO WELLNESS. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MISS
Authorized Official - First Name:NORMA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:OWNER
Authorized Official - Phone:747-204-4177
Mailing Address - Street 1:22110 ROSCOE BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91304-3861
Mailing Address - Country:US
Mailing Address - Phone:747-204-4177
Mailing Address - Fax:818-431-8283
Practice Address - Street 1:22110 ROSCOE BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:CANOGA PARK
Practice Address - State:CA
Practice Address - Zip Code:91304-3861
Practice Address - Country:US
Practice Address - Phone:747-204-4177
Practice Address - Fax:818-431-8283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-28
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty