Healthcare Provider Details

I. General information

NPI: 1821852989
Provider Name (Legal Business Name): INNERVISION WELLNESS SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2024
Last Update Date: 09/20/2024
Certification Date: 09/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

683 COTTAGE ST NE
SALEM OR
97301-2419
US

IV. Provider business mailing address

683 COTTAGE ST NE
SALEM OR
97301-2419
US

V. Phone/Fax

Practice location:
  • Phone: 336-314-7105
  • Fax:
Mailing address:
  • Phone: 336-314-7105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code332U00000X
TaxonomyHome Delivered Meals
License Number
License Number State

VIII. Authorized Official

Name: EBONY WIGGINS
Title or Position: DIRECTOR
Credential:
Phone: 336-314-7105