Provider Demographics
NPI:1205299617
Name:WELLNESS DIAGNOSTICS & MEDISPA, INC
Entity type:Organization
Organization Name:WELLNESS DIAGNOSTICS & MEDISPA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GLORIA MARIE F
Authorized Official - Middle Name:K
Authorized Official - Last Name:TUMBAGA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-387-3302
Mailing Address - Street 1:2751 RECHE CANYON RD
Mailing Address - Street 2:SPC 143
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-9570
Mailing Address - Country:US
Mailing Address - Phone:808-387-3302
Mailing Address - Fax:
Practice Address - Street 1:2751 RECHE CANYON RD
Practice Address - Street 2:SPC 143
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-9570
Practice Address - Country:US
Practice Address - Phone:808-387-3302
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-02
Last Update Date:2016-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty