Provider Demographics
NPI:1629345590
Name:GLOBAL NUTRACEUTICALS, INC
Entity Type:Organization
Organization Name:GLOBAL NUTRACEUTICALS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLA
Authorized Official - Middle Name:
Authorized Official - Last Name:LILLY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:949-366-0432
Mailing Address - Street 1:140 AVENIDA ALGODON
Mailing Address - Street 2:UNIT B
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-4182
Mailing Address - Country:US
Mailing Address - Phone:949-366-0432
Mailing Address - Fax:949-542-7020
Practice Address - Street 1:140 AVENIDA ALGODON
Practice Address - Street 2:UNIT B
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-4182
Practice Address - Country:US
Practice Address - Phone:949-366-0432
Practice Address - Fax:949-542-7020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-21
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A4676261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder