Provider Demographics
NPI:1710533948
Name:WELLNESS SOLUTION MEDICAL GROUP INC
Entity Type:Organization
Organization Name:WELLNESS SOLUTION MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:GAMBLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-487-1795
Mailing Address - Street 1:12115 MAGNOLIA BLVD # 14
Mailing Address - Street 2:
Mailing Address - City:N HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91607-2609
Mailing Address - Country:US
Mailing Address - Phone:818-487-1795
Mailing Address - Fax:
Practice Address - Street 1:6719 GREENBUSH AVE
Practice Address - Street 2:
Practice Address - City:VALLEY GLEN
Practice Address - State:CA
Practice Address - Zip Code:91401-1204
Practice Address - Country:US
Practice Address - Phone:818-487-1795
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-13
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA76121OtherCA MEDICAL BOARD