Provider Demographics
NPI:1639824105
Name:WONDERMED OF CALIFORNIA, INC
Entity Type:Organization
Organization Name:WONDERMED OF CALIFORNIA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COMPLIANCE
Authorized Official - Prefix:
Authorized Official - First Name:SANTINO
Authorized Official - Middle Name:
Authorized Official - Last Name:LABATE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-201-6090
Mailing Address - Street 1:828 CRESTMOORE PL
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-4931
Mailing Address - Country:US
Mailing Address - Phone:310-692-1469
Mailing Address - Fax:
Practice Address - Street 1:828 CRESTMOORE PL
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-4931
Practice Address - Country:US
Practice Address - Phone:310-692-1469
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-14
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty