Healthcare Provider Details

I. General information

NPI: 1689119646
Provider Name (Legal Business Name): INDWELL HEALTH AND WELLNESS.LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2016
Last Update Date: 04/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1019A VISTA PARK DR
FOREST VA
24551-4901
US

IV. Provider business mailing address

PO BOX 13103
ROANOKE VA
24031-3103
US

V. Phone/Fax

Practice location:
  • Phone: 434-515-0419
  • Fax: 844-693-9305
Mailing address:
  • Phone: 434-251-0026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101056392
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License Number0101056392
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number0101056392
License Number StateVA

VIII. Authorized Official

Name: DR. LUIS A MATOS
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 434-252-0026