Provider Demographics
NPI:1336321520
Name:NOURISHING WELLNESS INC
Entity Type:Organization
Organization Name:NOURISHING WELLNESS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-373-7830
Mailing Address - Street 1:819 N HARBOR DR
Mailing Address - Street 2:SUITE 310
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-2006
Mailing Address - Country:US
Mailing Address - Phone:310-373-7830
Mailing Address - Fax:310-373-7840
Practice Address - Street 1:819 N HARBOR DR
Practice Address - Street 2:SUITE 310
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-2006
Practice Address - Country:US
Practice Address - Phone:310-373-7830
Practice Address - Fax:310-373-7840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-29
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG16945207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACE629AMedicare PIN
CACE629AMedicare PIN