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General NPI Number Information
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NPI Number | 1063374601
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Entity Type | Organization
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Legal Business Name | LEBANON WELLNESS
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Dates
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Enumeration Date | 12/02/2025
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Last Update Date | 12/02/2025
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Provider Practice Location Address
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Address Line | 245 BLOOMFIELD DR STE 210
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City | LITITZ
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State | PA
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Zip | 17543-7788
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Country | US
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Telephone | 717-297-7900
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Fax | 717-276-7323
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Provider Business Mailing Address
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Address Line | 974 ISABEL DR
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City | LEBANON
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State | PA
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Zip | 17042-7482
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Country | US
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Telephone | 717-297-7900
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Fax | 717-276-7323
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Authorized Official
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Title or Position | PRESIDENT
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Name | SHAVKAT R RUZIEV
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Credential | MD
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Telephone | 717-297-7900
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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