Provider Demographics
NPI:1932315835
Name:SPORTS WELLNESS CENTER
Entity Type:Organization
Organization Name:SPORTS WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:LAWRENCE
Authorized Official - Last Name:SHAEVITZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-692-7138
Mailing Address - Street 1:22222 LA PALMA AVE
Mailing Address - Street 2:
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92887-3813
Mailing Address - Country:US
Mailing Address - Phone:714-692-7138
Mailing Address - Fax:714-692-7141
Practice Address - Street 1:22222 LA PALMA AVE
Practice Address - Street 2:
Practice Address - City:YORBA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92887-3813
Practice Address - Country:US
Practice Address - Phone:714-692-7138
Practice Address - Fax:714-692-7141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC23109111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty