Provider Demographics
NPI:1487029070
Name:WISE WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:WISE WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACUPUNCTURIST
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:TOYOSHIMA
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:619-339-8407
Mailing Address - Street 1:5080 LOVERS LN
Mailing Address - Street 2:SUITE C
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-1570
Mailing Address - Country:US
Mailing Address - Phone:619-339-8407
Mailing Address - Fax:
Practice Address - Street 1:5080 LOVERS LN
Practice Address - Street 2:SUITE C
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-1570
Practice Address - Country:US
Practice Address - Phone:619-339-8407
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-08
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14827171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty