=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194202630
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTEGRATE HEALTH AND WELLNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2018
-----------------------------------------------------
Last Update Date | 07/27/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 133 KEYBRIDGE DR STE B
-----------------------------------------------------
City | MORRISVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27560-5915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-378-9927
-----------------------------------------------------
Fax | 919-650-1861
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 133 KEYBRIDGE DR STE B
-----------------------------------------------------
City | MORRISVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27560-5915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-378-9927
-----------------------------------------------------
Fax | 919-650-1861
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CHIROPRATOR
-----------------------------------------------------
Name | ANTHONY WITHERSPOON
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 919-378-9927
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 4729
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------