Provider Demographics
NPI:1851759070
Name:SHORELINE WELLNESS MULTI
Entity Type:Organization
Organization Name:SHORELINE WELLNESS MULTI
Other - Org Name:SHORELINE WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MADHU
Authorized Official - Middle Name:
Authorized Official - Last Name:KATAKIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:424-287-5555
Mailing Address - Street 1:1360 W 6TH ST STE 165
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-3540
Mailing Address - Country:US
Mailing Address - Phone:424-287-5555
Mailing Address - Fax:310-872-5508
Practice Address - Street 1:1360 W 6TH ST STE 165
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-3540
Practice Address - Country:US
Practice Address - Phone:424-287-5555
Practice Address - Fax:310-872-5508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-02
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center