Provider Demographics
NPI:1669852968
Name:THE WELLNESS CENTER
Entity Type:Organization
Organization Name:THE WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED ACUPUNCTURIST/ OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JODY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:MANGUM
Authorized Official - Suffix:
Authorized Official - Credentials:MSOM
Authorized Official - Phone:707-487-4444
Mailing Address - Street 1:415 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SMITH RIVER
Mailing Address - State:CA
Mailing Address - Zip Code:95567-9519
Mailing Address - Country:US
Mailing Address - Phone:707-487-4444
Mailing Address - Fax:
Practice Address - Street 1:415 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:SMITH RIVER
Practice Address - State:CA
Practice Address - Zip Code:95567-9519
Practice Address - Country:US
Practice Address - Phone:707-487-4444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-02
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC7529171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1548387616OtherNPPES