Basic Information
| Provider Information | |||||||||
| NPI: | 1316118789 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WISE & HEALTHY AGING | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1527 4TH ST | ||||||||
| Address2: | |||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904012358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103949871 | ||||||||
| FaxNumber: | 3105762449 | ||||||||
| Practice Location | |||||||||
| Address1: | 1527 4TH ST | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904012358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103949871 | ||||||||
| FaxNumber: | 3103950863 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2008 | ||||||||
| LastUpdateDate: | 09/20/2022 | ||||||||
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| AuthorizedOfficialLastName: | DAVIES | ||||||||
| AuthorizedOfficialFirstName: | MOLLY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 3103949871 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 09/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 261QA0600X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Day Care |
No ID Information.