Healthcare Provider Details

I. General information

NPI: 1255612859
Provider Name (Legal Business Name): INTEGRATED WELLNESS PROVIDERS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2011
Last Update Date: 09/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3847 OLD US HIGHWAY 278 E
HOKES BLUFF AL
35903-7507
US

IV. Provider business mailing address

PO BOX 2336
GADSDEN AL
35903-0336
US

V. Phone/Fax

Practice location:
  • Phone: 256-494-5053
  • Fax:
Mailing address:
  • Phone: 256-494-5053
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2309
License Number StateAL

VIII. Authorized Official

Name: DR. JANICE MARIE WAGNER
Title or Position: PRESIDENT/CHIROPRACTIC PHYSICIAN
Credential: DC
Phone: 256-494-5053