Provider Demographics
NPI:1396210373
Name:WHOLESOME COMMUNITY MEMBERS CLUB INC
Entity Type:Organization
Organization Name:WHOLESOME COMMUNITY MEMBERS CLUB INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:MELVIN
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:818-239-9586
Mailing Address - Street 1:PO BOX 1763
Mailing Address - Street 2:
Mailing Address - City:SUN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91353-1763
Mailing Address - Country:US
Mailing Address - Phone:818-239-9586
Mailing Address - Fax:
Practice Address - Street 1:6309 VAN NUYS BLVD STE 102
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91401-6629
Practice Address - Country:US
Practice Address - Phone:818-239-9586
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-05
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No251V00000XAgenciesVoluntary or CharitableGroup - Single Specialty