Provider Demographics
NPI:1699123737
Name:WELL MEDICAL, A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:WELL MEDICAL, A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ILDAR
Authorized Official - Middle Name:
Authorized Official - Last Name:FAZULYANOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-384-0970
Mailing Address - Street 1:2280 SAWTELLE BLVD. # 101
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064
Mailing Address - Country:US
Mailing Address - Phone:310-384-0970
Mailing Address - Fax:
Practice Address - Street 1:929 COLORADO AVE
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-2716
Practice Address - Country:US
Practice Address - Phone:424-221-5012
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-31
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty