Provider Demographics
NPI:1154627925
Name:PHYSICIAN NUTRACEUTICAL RESEARCH, INC
Entity Type:Organization
Organization Name:PHYSICIAN NUTRACEUTICAL RESEARCH, INC
Other - Org Name:DR. WILLA'S HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WILLA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:LILLY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:888-508-3371
Mailing Address - Street 1:140 AVENIDA ALGODON
Mailing Address - Street 2:#A, B & C
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-4182
Mailing Address - Country:US
Mailing Address - Phone:888-508-3371
Mailing Address - Fax:949-481-7063
Practice Address - Street 1:140 AVENIDA ALGODON
Practice Address - Street 2:#A, B & C
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-4182
Practice Address - Country:US
Practice Address - Phone:888-508-3371
Practice Address - Fax:949-481-7063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-26
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA300189AP324500000X
CA300189BP324500000X
CA300189CP324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility