Provider Demographics
NPI:1306252986
Name:EWELLNESS CORPORATION
Entity type:Organization
Organization Name:EWELLNESS CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DARWIN
Authorized Official - Middle Name:
Authorized Official - Last Name:FOGT
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:310-915-6100
Mailing Address - Street 1:322 CULVER BLVD # 217
Mailing Address - Street 2:
Mailing Address - City:PLAYA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90293-7704
Mailing Address - Country:US
Mailing Address - Phone:310-915-6100
Mailing Address - Fax:
Practice Address - Street 1:747 3RD AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10017-2803
Practice Address - Country:US
Practice Address - Phone:310-915-6100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-03
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty