Healthcare Provider Details

I. General information

NPI: 1699454975
Provider Name (Legal Business Name): INNOVATIVE WELLNESS CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2023
Last Update Date: 07/14/2023
Certification Date: 07/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1809 CORLIES AVENUE
NEPTUNE NJ
07753
US

IV. Provider business mailing address

1809 CORLIES AVENUE
NEPTUNE NJ
07753
US

V. Phone/Fax

Practice location:
  • Phone: 732-618-3220
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: ROBERT KHAMISH
Title or Position: OWNER
Credential:
Phone: 732-618-3220