Basic Information
Provider Information | |||||||||
NPI: | 1508123753 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SIMON WELLNESS LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2980 N BEVERLY GLEN CIR | ||||||||
Address2: | SUITE 100 | ||||||||
City: | LOS ANGELES | ||||||||
State: | CA | ||||||||
PostalCode: | 900771726 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3104749809 | ||||||||
FaxNumber: | 8884318819 | ||||||||
Practice Location | |||||||||
Address1: | 4500 9TH AVE NE | ||||||||
Address2: | SUITE 300 | ||||||||
City: | SEATTLE | ||||||||
State: | WA | ||||||||
PostalCode: | 981054737 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2065240863 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/12/2012 | ||||||||
LastUpdateDate: | 10/05/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SIMON | ||||||||
AuthorizedOfficialFirstName: | MICHELLE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRINCIPAL | ||||||||
AuthorizedOfficialTelephone: | 2065240863 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | SIMON WELLNESS LLC | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | ND | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X |   |   | Y |   | Suppliers | Non-Pharmacy Dispensing Site |   |
No ID Information.