Basic Information
| Provider Information | |||||||||
| NPI: | 1134399165 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WISE &HEALTHY AGING | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1527 4TH ST | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904012358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103949871 | ||||||||
| FaxNumber: | 3105762499 | ||||||||
| Practice Location | |||||||||
| Address1: | 1527 4TH ST | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904012358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103949871 | ||||||||
| FaxNumber: | 3105762499 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2008 | ||||||||
| LastUpdateDate: | 09/17/2013 | ||||||||
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| AuthorizedOfficialLastName: | BRAUN | ||||||||
| AuthorizedOfficialFirstName: | GRACE | ||||||||
| AuthorizedOfficialMiddleName: | CHENG | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 3103949871 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | W13662 | 01 | CA | MEDICARE PROVIDER NUMBER | OTHER |