Provider Demographics
NPI:1548393119
Name:WOMENS HEALTH & WELLNESS MEDICAL OFFICE, INC
Entity Type:Organization
Organization Name:WOMENS HEALTH & WELLNESS MEDICAL OFFICE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:R
Authorized Official - Last Name:BROAD
Authorized Official - Suffix:
Authorized Official - Credentials:RNP
Authorized Official - Phone:951-304-3180
Mailing Address - Street 1:40700 CALIFORNIA OAKS RD
Mailing Address - Street 2:STE. 205
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-5789
Mailing Address - Country:US
Mailing Address - Phone:951-304-3180
Mailing Address - Fax:951-304-2735
Practice Address - Street 1:40700 CALIFORNIA OAKS RD
Practice Address - Street 2:STE. 205
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-5789
Practice Address - Country:US
Practice Address - Phone:951-304-3180
Practice Address - Fax:951-304-2735
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA428809363LA2200X, 363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1467449975Medicare ID - Type UnspecifiedNPI MEDICARE
CAR21693Medicare UPIN