Provider Demographics
NPI:1740519727
Name:SANTA CLARA WELLNESS CENTER
Entity type:Organization
Organization Name:SANTA CLARA WELLNESS CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:E
Authorized Official - Last Name:WETTACH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-258-8050
Mailing Address - Street 1:2179 TULLY RD
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95122-1346
Mailing Address - Country:US
Mailing Address - Phone:408-258-8050
Mailing Address - Fax:408-258-2269
Practice Address - Street 1:2179 TULLY RD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95122-1346
Practice Address - Country:US
Practice Address - Phone:408-258-8050
Practice Address - Fax:408-258-2269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-21
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC31903207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty