Provider Demographics
NPI:1184081309
Name:FORD WELLNESS CENTER, A MEDICAL CORPORATION
Entity type:Organization
Organization Name:FORD WELLNESS CENTER, A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:844-392-7844
Mailing Address - Street 1:2980 N BEVERLY GLEN CIR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90077-1726
Mailing Address - Country:US
Mailing Address - Phone:310-943-4180
Mailing Address - Fax:888-431-8819
Practice Address - Street 1:7901 SANTA MONICA BLVD
Practice Address - Street 2:SUITE 209
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90046-5177
Practice Address - Country:US
Practice Address - Phone:844-392-7844
Practice Address - Fax:888-431-8819
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FORD WELLNESS CENTER, A MEDICAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-01-19
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA122580332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site