1104408780 NPI number — IMMERSIVE WELLNESS CENTERS, LLC

Table of content: (NPI 1104408780)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104408780 NPI number — IMMERSIVE WELLNESS CENTERS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IMMERSIVE WELLNESS CENTERS, LLC
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:
1104408780
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/23/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
34145 PACIFIC COAST HWY # 728
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DANA POINT
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92629-2808
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-871-7345
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 CRISTIANITOS ROAD
Provider Second Line Business Practice Location Address:
UNIT 14207
Provider Business Practice Location Address City Name:
SAN CLEMENTE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92673
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-871-7345
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/23/2021

Additional Information

Authorized Official

Authorized Official Last Name:
MCMAHON
Authorized Official First Name:
ANGELA
Authorized Official Middle Name:
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
619-871-7345

Provider Taxonomy Codes

  • Taxonomy code: 261QR0405X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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