Provider Demographics
NPI:1831718022
Name:RISE OF THE PHOENIX WHOLE HEALTH CENTER
Entity type:Organization
Organization Name:RISE OF THE PHOENIX WHOLE HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:805-405-1250
Mailing Address - Street 1:810 COOPER AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90042-1516
Mailing Address - Country:US
Mailing Address - Phone:805-405-1250
Mailing Address - Fax:
Practice Address - Street 1:1703 N AVALON BLVD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:CA
Practice Address - Zip Code:90744-1432
Practice Address - Country:US
Practice Address - Phone:805-405-1250
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-09
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty