1053839175 NPI number — MS. WELLNESS NUTRITION, INC.

Table of content: (NPI 1053839175)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053839175 NPI number — MS. WELLNESS NUTRITION, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MS. WELLNESS NUTRITION, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053839175
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/08/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
276 PALM VALLEY BLVD APT 205
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN JOSE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95123-1049
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-775-6252
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21030 REDWOOD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CASTRO VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94546-5920
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-538-0430
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/08/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CHIU
Authorized Official First Name:
MIE MIE
Authorized Official Middle Name:
Authorized Official Title or Position:
REGISTERED DIETITIAN/OWNER
Authorized Official Telephone Number:
858-775-6252

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  863957 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 133VN1005X , with the licence number: 863957 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 133VN1006X , with the licence number: 863957 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)