Provider Demographics
NPI:1386182079
Name:STATE OF THE HEART WELLNESS
Entity Type:Organization
Organization Name:STATE OF THE HEART WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER 50/50
Authorized Official - Prefix:DR
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROACH-GAGNON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:408-972-5686
Mailing Address - Street 1:7174 SANTA TERESA BLVD STE A7
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95139-1350
Mailing Address - Country:US
Mailing Address - Phone:408-972-5686
Mailing Address - Fax:408-972-5682
Practice Address - Street 1:7174 SANTA TERESA BLVD STE A7
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95139-1350
Practice Address - Country:US
Practice Address - Phone:408-972-5686
Practice Address - Fax:408-972-5682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-02
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC23580111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty