Provider Demographics
NPI:1134399165
Name:WISE &HEALTHY AGING
Entity type:Organization
Organization Name:WISE &HEALTHY AGING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:CHENG
Authorized Official - Last Name:BRAUN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-394-9871
Mailing Address - Street 1:1527 4TH ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90401-2358
Mailing Address - Country:US
Mailing Address - Phone:310-394-9871
Mailing Address - Fax:310-576-2499
Practice Address - Street 1:1527 4TH ST
Practice Address - Street 2:3RD FLOOR
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-2358
Practice Address - Country:US
Practice Address - Phone:310-394-9871
Practice Address - Fax:310-576-2499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-05
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW13662OtherMEDICARE PROVIDER NUMBER