Healthcare Provider Details

I. General information

NPI: 1063374601
Provider Name (Legal Business Name): LEBANON WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2025
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 BLOOMFIELD DR STE 210
LITITZ PA
17543-7788
US

IV. Provider business mailing address

974 ISABEL DR
LEBANON PA
17042-7482
US

V. Phone/Fax

Practice location:
  • Phone: 717-297-7900
  • Fax: 717-276-7323
Mailing address:
  • Phone: 717-297-7900
  • Fax: 717-276-7323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: SHAVKAT R RUZIEV
Title or Position: PRESIDENT
Credential: MD
Phone: 717-297-7900