Provider Demographics
NPI:1336856830
Name:WELLNESS HEALTH MEDICAL PROVIDER, P.C.
Entity Type:Organization
Organization Name:WELLNESS HEALTH MEDICAL PROVIDER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF LEGAL
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BOSHARDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-814-3028
Mailing Address - Street 1:17981 SKY PARK CIR, BLDG 39, STE BC
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-6309
Mailing Address - Country:US
Mailing Address - Phone:949-325-7001
Mailing Address - Fax:949-309-2797
Practice Address - Street 1:1 LAURA LN
Practice Address - Street 2:
Practice Address - City:EAST NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11731-4700
Practice Address - Country:US
Practice Address - Phone:949-325-7001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-03
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care