Provider Demographics
NPI:1104193192
Name:GOOGLE WELLNESS CENTER, 321
Entity Type:Organization
Organization Name:GOOGLE WELLNESS CENTER, 321
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:LEES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-348-4214
Mailing Address - Street 1:321 HAMPTON DR.
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291
Mailing Address - Country:US
Mailing Address - Phone:650-214-6369
Mailing Address - Fax:650-253-2302
Practice Address - Street 1:321 HAMPTON DR
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-2696
Practice Address - Country:US
Practice Address - Phone:650-214-6369
Practice Address - Fax:650-253-2302
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHS HEALTH SERVICES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-11-19
Last Update Date:2011-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA 73520332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site