Healthcare Provider Details

I. General information

NPI: 1922367754
Provider Name (Legal Business Name): INNERACTIVE WELLNESS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2012
Last Update Date: 05/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 ALBANY ST
CAZENOVIA NY
13035-1231
US

IV. Provider business mailing address

132 ALBANY ST
CAZENOVIA NY
13035-1231
US

V. Phone/Fax

Practice location:
  • Phone: 315-655-1055
  • Fax: 315-207-3021
Mailing address:
  • Phone: 315-655-1055
  • Fax: 315-207-3021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number33D1057519
License Number StateNY

VIII. Authorized Official

Name: EUGENE BAILEY
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 315-655-1055