Healthcare Provider Details

I. General information

NPI: 1699644336
Provider Name (Legal Business Name): INTEGRAL WELLNESS BOUTIQUE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2025
Last Update Date: 10/31/2025
Certification Date: 10/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15685 HAWTHORNE BLVD STE H
LAWNDALE CA
90260-3912
US

IV. Provider business mailing address

28201 FRANKLIN PKWY UNIT 27
SANTA CLARITA CA
91310-7002
US

V. Phone/Fax

Practice location:
  • Phone: 818-308-0184
  • Fax:
Mailing address:
  • Phone: 818-308-0184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: ANN DEVINE
Title or Position: MANAGER
Credential:
Phone: 818-308-0184