Healthcare Provider Details

I. General information

NPI: 1497360978
Provider Name (Legal Business Name): IOB WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2020
Last Update Date: 06/07/2021
Certification Date: 06/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5060 N 19TH AVE # 406-9
PHOENIX AZ
85015-3210
US

IV. Provider business mailing address

11114 W COLLEGE DR
PHOENIX AZ
85037-1269
US

V. Phone/Fax

Practice location:
  • Phone: 623-777-0082
  • Fax:
Mailing address:
  • Phone: 623-777-0082
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ERIC NBIZI
Title or Position: OWNER
Credential:
Phone: 623-777-0082