Healthcare Provider Details

I. General information

NPI: 1497083083
Provider Name (Legal Business Name): INTEGRATED WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2009
Last Update Date: 08/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11500 WEBB BRIDGE WAY SUITE 5A
ALPHARETTA GA
30005-2046
US

IV. Provider business mailing address

11500 WEBB BRIDGE WAY SUITE 5A
ALPHARETTA GA
30005-2046
US

V. Phone/Fax

Practice location:
  • Phone: 770-521-8994
  • Fax:
Mailing address:
  • Phone: 770-521-8994
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. DAVID L WIZNITZER
Title or Position: MEMBER
Credential: D.C.
Phone: 770-521-8994