Provider Demographics
NPI:1497262695
Name:MEGA WELLNESS CLINIC NURSING PRACTITIONER INC
Entity Type:Organization
Organization Name:MEGA WELLNESS CLINIC NURSING PRACTITIONER INC
Other - Org Name:WELLNESSCLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:NP
Authorized Official - Prefix:MRS
Authorized Official - First Name:AE RAH
Authorized Official - Middle Name:
Authorized Official - Last Name:KANG
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE PRACTITIONER
Authorized Official - Phone:714-784-6767
Mailing Address - Street 1:432 S BREA BLVD
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-5301
Mailing Address - Country:US
Mailing Address - Phone:714-784-6767
Mailing Address - Fax:714-784-6757
Practice Address - Street 1:432 S BREA BLVD
Practice Address - Street 2:
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-5301
Practice Address - Country:US
Practice Address - Phone:714-784-6767
Practice Address - Fax:714-784-6757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-09
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA4078207R00000X
CA18049363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty