Provider Demographics
NPI:1720299308
Name:WHOLE CHILD WELLNESS, INC
Entity Type:Organization
Organization Name:WHOLE CHILD WELLNESS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELISA
Authorized Official - Middle Name:
Authorized Official - Last Name:SONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-595-5437
Mailing Address - Street 1:1601 EL CAMINO REAL
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BELMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94002-3948
Mailing Address - Country:US
Mailing Address - Phone:650-595-5437
Mailing Address - Fax:650-595-5438
Practice Address - Street 1:1601 EL CAMINO REAL
Practice Address - Street 2:SUITE 101
Practice Address - City:BELMONT
Practice Address - State:CA
Practice Address - Zip Code:94002-3948
Practice Address - Country:US
Practice Address - Phone:650-595-5437
Practice Address - Fax:650-595-5438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133N00000X
CAA68766208000000X
CAA64193208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty