Provider Demographics
NPI:1194898726
Name:WELLNESS CARE MEDICAL GROUP A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:WELLNESS CARE MEDICAL GROUP A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARIBETH
Authorized Official - Middle Name:
Authorized Official - Last Name:SALVATIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-221-0177
Mailing Address - Street 1:416 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94118-2812
Mailing Address - Country:US
Mailing Address - Phone:415-221-0177
Mailing Address - Fax:
Practice Address - Street 1:416 16TH AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94118-2812
Practice Address - Country:US
Practice Address - Phone:415-221-0177
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1194898726Medicaid
CA1194898726Medicaid