Provider Demographics
NPI:1083251532
Name:PRIME WELLNESS COMMUNITY HEALTH CENTER
Entity Type:Organization
Organization Name:PRIME WELLNESS COMMUNITY HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DENYS
Authorized Official - Middle Name:
Authorized Official - Last Name:SLESARENKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-659-7867
Mailing Address - Street 1:8610 S SEPULVEDA BLVD STE 104
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-4009
Mailing Address - Country:US
Mailing Address - Phone:310-659-7867
Mailing Address - Fax:310-878-2118
Practice Address - Street 1:8610 S SEPULVEDA BLVD STE 104
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-4009
Practice Address - Country:US
Practice Address - Phone:310-659-7867
Practice Address - Fax:310-878-2118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-03
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health