Provider Demographics
NPI:1073761466
Name:WHITAKER WELLNESS INSTITUTE MEDICAL CLINIC INC
Entity Type:Organization
Organization Name:WHITAKER WELLNESS INSTITUTE MEDICAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LABORATORY DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITAKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-851-1550
Mailing Address - Street 1:4321 BIRCH ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-1923
Mailing Address - Country:US
Mailing Address - Phone:949-851-1550
Mailing Address - Fax:
Practice Address - Street 1:4321 BIRCH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-1923
Practice Address - Country:US
Practice Address - Phone:949-851-1550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WHITAKER WELLNESS INSTITUTE MEDICAL CLINIC INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-08-28
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLF 11147291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACLF 11147OtherDEPARTMENT OF HEALTH SERVICES