Provider Demographics
NPI:1932461902
Name:DRMICHAELS WELLNESS CENTER
Entity Type:Organization
Organization Name:DRMICHAELS WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIOS
Authorized Official - Middle Name:
Authorized Official - Last Name:MICHAEL
Authorized Official - Suffix:I
Authorized Official - Credentials:CNS
Authorized Official - Phone:626-440-7406
Mailing Address - Street 1:424 N LAKE AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-1202
Mailing Address - Country:US
Mailing Address - Phone:626-440-7406
Mailing Address - Fax:
Practice Address - Street 1:424 N LAKE AVE STE 102
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-1202
Practice Address - Country:US
Practice Address - Phone:626-440-7406
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-14
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACNS16073133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACNS16073OtherAMA