Healthcare Provider Details

I. General information

NPI: 1417879974
Provider Name (Legal Business Name): INTEGRATED WELLNESS & WEIGHTLOSS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2026
Last Update Date: 07/28/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9629 FAIRFAX BLVD STE 211
FAIRFAX VA
22031-2321
US

IV. Provider business mailing address

26081 WENDELL ST
CHANTILLY VA
20152-3403
US

V. Phone/Fax

Practice location:
  • Phone: 571-435-0186
  • Fax:
Mailing address:
  • Phone: 571-435-0186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: JEDDIE GARCIA
Title or Position: FNP
Credential: DNP, APN, FNP-C
Phone: 973-978-0174