Healthcare Provider Details

I. General information

NPI: 1588528699
Provider Name (Legal Business Name): RENOVAR WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2025
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 KILBOURN ST
ELKHART IN
46514-1920
US

IV. Provider business mailing address

1750 KILBOURN ST
ELKHART IN
46514-1920
US

V. Phone/Fax

Practice location:
  • Phone: 574-387-6260
  • Fax:
Mailing address:
  • Phone: 574-387-6260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: ABDUL MALIK
Title or Position: MD
Credential: MD
Phone: 574-387-6260