Provider Demographics
NPI:1508961400
Name:EXECUTIVE WELLNESS
Entity Type:Organization
Organization Name:EXECUTIVE WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CASEY
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:MAGUIRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-218-2600
Mailing Address - Street 1:PO BOX 14155
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92863-1555
Mailing Address - Country:US
Mailing Address - Phone:310-218-2600
Mailing Address - Fax:310-541-8280
Practice Address - Street 1:8 QUAIL RIDGE RD S
Practice Address - Street 2:
Practice Address - City:ROLLING HILLS
Practice Address - State:CA
Practice Address - Zip Code:90274-5017
Practice Address - Country:US
Practice Address - Phone:310-218-2600
Practice Address - Fax:310-541-8280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty