Healthcare Provider Details

I. General information

NPI: 1760175723
Provider Name (Legal Business Name): INTEGRATED WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2023
Last Update Date: 05/30/2023
Certification Date: 05/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2316 W NORTHERN AVE
PHOENIX AZ
85021-4935
US

IV. Provider business mailing address

5523 S JOLLY ROGER RD
TEMPE AZ
85283-2118
US

V. Phone/Fax

Practice location:
  • Phone: 602-838-7799
  • Fax: 602-844-2525
Mailing address:
  • Phone: 650-847-8861
  • Fax: 602-844-2525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: RAVIKULASINGHAM THURAISINGAM
Title or Position: ADMINISTRATOR
Credential:
Phone: 650-847-8861