Provider Demographics
NPI:1437404142
Name:WILLIAM C TA MDSPECTRUM MEDICAL & WELLNESS CENTER
Entity Type:Organization
Organization Name:WILLIAM C TA MDSPECTRUM MEDICAL & WELLNESS CENTER
Other - Org Name:SPECTRUM MEDICAL & WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:ONYENKWERE
Authorized Official - Middle Name:O
Authorized Official - Last Name:OKWANDU
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:760-246-9555
Mailing Address - Street 1:15095 AMARGOSA RD
Mailing Address - Street 2:BLDG 2, STE 280
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92394-1879
Mailing Address - Country:US
Mailing Address - Phone:760-952-9100
Mailing Address - Fax:760-952-9228
Practice Address - Street 1:15095 AMARGOSA RD
Practice Address - Street 2:BLDG 2, STE 280
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92394-1879
Practice Address - Country:US
Practice Address - Phone:760-952-9100
Practice Address - Fax:760-952-9228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-18
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA118947261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center