Provider Demographics
NPI:1376681486
Name:WATTS HEALTHCARE CORPORATION
Entity Type:Organization
Organization Name:WATTS HEALTHCARE CORPORATION
Other - Org Name:JORDAN WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:D
Authorized Official - Last Name:HOBSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:323-568-4417
Mailing Address - Street 1:10110 JUNIPER STREET
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90002
Mailing Address - Country:US
Mailing Address - Phone:323-357-6680
Mailing Address - Fax:323-563-6378
Practice Address - Street 1:10300 COMPTON AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90002-3628
Practice Address - Country:US
Practice Address - Phone:323-357-6680
Practice Address - Fax:323-563-6378
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WATTS HEALTHCARE CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-01
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA96000449261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC70422GMedicaid
CAFHC70422GMedicaid