Provider Demographics
NPI:1841765674
Name:PISMO WELLNESS INC., A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:PISMO WELLNESS INC., A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JESSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTORI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-920-4290
Mailing Address - Street 1:8500 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211
Mailing Address - Country:US
Mailing Address - Phone:424-307-9504
Mailing Address - Fax:
Practice Address - Street 1:8500 WILSHIRE BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211
Practice Address - Country:US
Practice Address - Phone:424-307-9504
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-08
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)