Provider Demographics
NPI:1790094555
Name:LA HEALTH & WELLNESS MEDICAL GROUP
Entity Type:Organization
Organization Name:LA HEALTH & WELLNESS MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:YANIV
Authorized Official - Middle Name:
Authorized Official - Last Name:FARBENBLOOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-505-0152
Mailing Address - Street 1:11239 VENTURA BLVD STE 213
Mailing Address - Street 2:
Mailing Address - City:STUDIO CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91604-3167
Mailing Address - Country:US
Mailing Address - Phone:818-505-0152
Mailing Address - Fax:818-505-0398
Practice Address - Street 1:11239 VENTURA BLVD STE 213
Practice Address - Street 2:
Practice Address - City:STUDIO CITY
Practice Address - State:CA
Practice Address - Zip Code:91604-3167
Practice Address - Country:US
Practice Address - Phone:818-505-0152
Practice Address - Fax:818-505-0398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-28
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG56249208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty