Provider Demographics
NPI:1386180222
Name:HEART AND WELLNESS CENTER A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:HEART AND WELLNESS CENTER A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARIUSZ
Authorized Official - Middle Name:W
Authorized Official - Last Name:WYSOCZANSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-434-4288
Mailing Address - Street 1:502 EUCLID AVE
Mailing Address - Street 2:SUITE #104
Mailing Address - City:NATIONAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91950-2931
Mailing Address - Country:US
Mailing Address - Phone:619-434-4288
Mailing Address - Fax:888-501-2443
Practice Address - Street 1:502 EUCLID AVE
Practice Address - Street 2:SUITE #104
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-2931
Practice Address - Country:US
Practice Address - Phone:619-434-4288
Practice Address - Fax:888-501-2443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-17
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC55986207RC0000X
CAA76050207RC0001X
CAA124001207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac ElectrophysiologyGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC55986Medicare PIN