Provider Demographics
NPI:1275265134
Name:WELLNESS OF SD LLC
Entity Type:Organization
Organization Name:WELLNESS OF SD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VINCENTE
Authorized Official - Middle Name:T
Authorized Official - Last Name:ORTIZ
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:805-727-1234
Mailing Address - Street 1:4150 ALBATROSS DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-1905
Mailing Address - Country:US
Mailing Address - Phone:805-727-1234
Mailing Address - Fax:
Practice Address - Street 1:5350 RILEY ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-2621
Practice Address - Country:US
Practice Address - Phone:805-727-1234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-29
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty