Provider Demographics
NPI:1306024179
Name:WELLNESS CENTER AT CENTURY CITY
Entity Type:Organization
Organization Name:WELLNESS CENTER AT CENTURY CITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:J
Authorized Official - Last Name:CHO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-553-6494
Mailing Address - Street 1:2080 CENTURY PARK E
Mailing Address - Street 2:SUITE 807
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90067-2001
Mailing Address - Country:US
Mailing Address - Phone:310-553-6494
Mailing Address - Fax:310-228-1030
Practice Address - Street 1:2080 CENTURY PARK E
Practice Address - Street 2:SUITE 807
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90067-2001
Practice Address - Country:US
Practice Address - Phone:310-553-6494
Practice Address - Fax:310-228-1030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-04
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA60860207R00000X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG72311Medicare UPIN