Provider Demographics
NPI:1487653036
Name:DIABETES WELLNESS CENTER, A NURSING CORPORATION
Entity Type:Organization
Organization Name:DIABETES WELLNESS CENTER, A NURSING CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KRISTINA
Authorized Official - Middle Name:N
Authorized Official - Last Name:DILWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:RN, MS, FNP
Authorized Official - Phone:805-773-3130
Mailing Address - Street 1:855 4TH ST
Mailing Address - Street 2:#2
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-3102
Mailing Address - Country:US
Mailing Address - Phone:805-773-3130
Mailing Address - Fax:805-773-3120
Practice Address - Street 1:855 4TH ST
Practice Address - Street 2:#2
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-3102
Practice Address - Country:US
Practice Address - Phone:805-773-3130
Practice Address - Fax:805-773-3120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-16
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC2445484133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, MetabolicGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW16524Medicare ID - Type Unspecified