Provider Demographics
NPI:1912278664
Name:CENTER FOR WELLNESS
Entity Type:Organization
Organization Name:CENTER FOR WELLNESS
Other - Org Name:OPTIMAL WELLNESS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRACTITIONER / PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:L
Authorized Official - Last Name:MORENO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:323-726-6289
Mailing Address - Street 1:420 N MONTEBELLO BLVD
Mailing Address - Street 2:300
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-4268
Mailing Address - Country:US
Mailing Address - Phone:323-726-6289
Mailing Address - Fax:323-726-6767
Practice Address - Street 1:420 N MONTEBELLO BLVD
Practice Address - Street 2:300
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-4268
Practice Address - Country:US
Practice Address - Phone:323-726-6289
Practice Address - Fax:323-726-6767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-25
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175L00000X, 204R00000X, 207QB0002X, 2083P0500X
CA20A6911208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No175L00000XOther Service ProvidersHomeopathGroup - Multi-Specialty
No204R00000XAllopathic & Osteopathic PhysiciansElectrodiagnostic MedicineGroup - Multi-Specialty
No207QB0002XAllopathic & Osteopathic PhysiciansFamily MedicineObesity MedicineGroup - Multi-Specialty
No2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental MedicineGroup - Multi-Specialty