Healthcare Provider Details

I. General information

NPI: 1255791976
Provider Name (Legal Business Name): INTEGRATED WELLNESS DC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2016
Last Update Date: 06/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 M ST NW
WASHINGTON DC
20036
US

IV. Provider business mailing address

9755 PATUXENT WOODS DR STE 100
COLUMBIA MD
21046-2286
US

V. Phone/Fax

Practice location:
  • Phone: 800-762-6282
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: CARL DOUGLAS LORD
Title or Position: OWNER
Credential: M.D.
Phone: 301-502-5566