Provider Demographics
NPI:1750752804
Name:WONDERFUL CENTER FOR HEALTH INNOVATION INC
Entity type:Organization
Organization Name:WONDERFUL CENTER FOR HEALTH INNOVATION INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLK
Authorized Official - Suffix:
Authorized Official - Credentials:MD MSPH
Authorized Official - Phone:661-720-2660
Mailing Address - Street 1:13646 HIGHWAY 33
Mailing Address - Street 2:
Mailing Address - City:LOST HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:93249-9719
Mailing Address - Country:US
Mailing Address - Phone:661-797-6606
Mailing Address - Fax:661-797-6667
Practice Address - Street 1:13646 HIGHWAY 33
Practice Address - Street 2:
Practice Address - City:LOST HILLS
Practice Address - State:CA
Practice Address - Zip Code:93249-9719
Practice Address - Country:US
Practice Address - Phone:661-797-6606
Practice Address - Fax:661-797-6667
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WONDERFUL CENTER FOR HEALTH INNOVATION INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-10-15
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC140498261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP50244Medicare UPIN