MEDICARE: IOB WELLNESS CENTER LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner
2	103TR0400X	Rehabilitation Psychologist
3	261QP2300X	Primary Care Clinic/Center
4	324500000X	Substance Abuse Rehabilitation Facility
5	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1497360978
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IOB WELLNESS CENTER LLC

Provider Business Mailing Address
First Line	:	11114 W COLLEGE DR
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85037-1269
Country	:	US
Telephone Number	:	623-777-0082
Fax Number	:

Provider Business Practice Location Address
First Line	:	5060 N 19TH AVE # 406-9
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85015-3210
Country	:	US
Telephone Number	:	623-777-0082
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ERIC NBIZI
Credential	:
Telephone Number	:	623-777-0082

Provider Enumeration Date	:	09/11/2020
Last Update Date	:	06/07/2021

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