Provider Demographics
NPI:1356835771
Name:ABSOLUTE WELLNESS MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:ABSOLUTE WELLNESS MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:NENITA
Authorized Official - Middle Name:
Authorized Official - Last Name:MEHLMAUER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-754-4955
Mailing Address - Street 1:1430 E PLAZA BLVD STE E18
Mailing Address - Street 2:
Mailing Address - City:NATIONAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91950-3690
Mailing Address - Country:US
Mailing Address - Phone:619-434-2813
Mailing Address - Fax:855-631-3720
Practice Address - Street 1:1430 E PLAZA BLVD STE E18
Practice Address - Street 2:
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-3690
Practice Address - Country:US
Practice Address - Phone:619-434-2813
Practice Address - Fax:855-631-3720
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-19
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1073579173Medicaid
CA1700314978Medicaid