MEDICARE: INTEGRATIVE WELLNESS CENTERS, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	073586	GA

General Provider Information

NPI Number	:	1396282182
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTEGRATIVE WELLNESS CENTERS, INC

Provider Business Mailing Address
First Line	:	3060 PEACHTREE RD NW
Second Line	:	SUITE 965
City	:	ATLANTA
State	:	GA
Zip	:	30305-2234
Country	:	US
Telephone Number	:	678-904-7564
Fax Number	:	678-904-7569

Provider Business Practice Location Address
First Line	:	1776 PEACHTREE ST NW
Second Line	:	SUITE 318N
City	:	ATLANTA
State	:	GA
Zip	:	30309-2307
Country	:	US
Telephone Number	:	678-705-4848
Fax Number	:	404-549-3393

Authorized Official
Title or Position	:	CEO
Name	:	DR. SHAILESH KOTHARI
Credential	:	DC
Telephone Number	:	678-705-4848

Provider Enumeration Date	:	01/31/2017
Last Update Date	:	01/31/2017

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