Provider Demographics
NPI:1578773669
Name:CAROLYN N. QUETZAL
Entity Type:Organization
Organization Name:CAROLYN N. QUETZAL
Other - Org Name:MOTHERS WELLNESS CONNECTION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:N
Authorized Official - Last Name:QUETZAL
Authorized Official - Suffix:
Authorized Official - Credentials:MED, DC
Authorized Official - Phone:818-757-3131
Mailing Address - Street 1:18340 VENTURA BLVD
Mailing Address - Street 2:SUITE 222
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-4234
Mailing Address - Country:US
Mailing Address - Phone:818-757-3131
Mailing Address - Fax:
Practice Address - Street 1:18340 VENTURA BLVD
Practice Address - Street 2:SUITE 222
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-4234
Practice Address - Country:US
Practice Address - Phone:818-757-3131
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC26621261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service