Provider Demographics
NPI:1417774399
Name:WAVE WELLNESS CLINIC PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:WAVE WELLNESS CLINIC PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:EMMA
Authorized Official - Middle Name:
Authorized Official - Last Name:DORANTES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-458-7539
Mailing Address - Street 1:4401 MANCHESTER AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-4938
Mailing Address - Country:US
Mailing Address - Phone:760-753-0220
Mailing Address - Fax:760-753-2639
Practice Address - Street 1:4407 MANCHESTER AVE STE 101
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-4941
Practice Address - Country:US
Practice Address - Phone:760-652-6800
Practice Address - Fax:760-274-6165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-23
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care