Provider Demographics
NPI:1053179911
Name:WHITEHEAD FAMILY WELLNESS CLINIC
Entity type:Organization
Organization Name:WHITEHEAD FAMILY WELLNESS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:AURELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITEHEAD
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:323-200-6418
Mailing Address - Street 1:12813 AVALON BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90061-2731
Mailing Address - Country:US
Mailing Address - Phone:310-819-8310
Mailing Address - Fax:310-819-8178
Practice Address - Street 1:12813 AVALON BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90061-2731
Practice Address - Country:US
Practice Address - Phone:310-819-8310
Practice Address - Fax:310-819-8178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-06
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care