Provider Demographics
NPI:1629753132
Name:LA CONCORDIA WELLNESS CENTER
Entity Type:Organization
Organization Name:LA CONCORDIA WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:FERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:925-849-4761
Mailing Address - Street 1:1070 CONCORD AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-5608
Mailing Address - Country:US
Mailing Address - Phone:925-849-4695
Mailing Address - Fax:925-270-3382
Practice Address - Street 1:1070 CONCORD AVE STE 105
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-5608
Practice Address - Country:US
Practice Address - Phone:925-849-4695
Practice Address - Fax:925-270-3382
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-21
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty