Healthcare Provider Details

I. General information

NPI: 1194335802
Provider Name (Legal Business Name): INTEGRATED MEDICAL WELLNESS CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2020
Last Update Date: 08/23/2020
Certification Date: 08/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10184 W HAPPY VALLEY PKWY STE 180
PEORIA AZ
85383-1254
US

IV. Provider business mailing address

10184 W HAPPY VALLEY PKWY STE 180
PEORIA AZ
85383-1254
US

V. Phone/Fax

Practice location:
  • Phone: 480-289-8464
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ANDRE DREVAL
Title or Position: MANAGING MEMBER
Credential:
Phone: 602-400-2800