Provider Demographics
NPI:1184246696
Name:PENINSULA WELLNESS CENTRE
Entity type:Organization
Organization Name:PENINSULA WELLNESS CENTRE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHNNY
Authorized Official - Middle Name:VAN
Authorized Official - Last Name:DUONG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:909-961-2429
Mailing Address - Street 1:2425 CALIFORNIA ST STE E
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94040-1462
Mailing Address - Country:US
Mailing Address - Phone:650-961-2429
Mailing Address - Fax:650-969-1107
Practice Address - Street 1:2425 CALLIFORNIA ST STE E
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94040
Practice Address - Country:US
Practice Address - Phone:650-961-2429
Practice Address - Fax:650-969-1107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-07
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty