=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194446237
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INNOVATIVE WELLNESS CENTERS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2022
-----------------------------------------------------
Last Update Date | 09/07/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7100 N HIGH STREET SUITE 201
-----------------------------------------------------
City | WORTHINGTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43085-2316
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-601-6272
-----------------------------------------------------
Fax | 614-601-6291
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7100 N HIGH STREET SUITE 201
-----------------------------------------------------
City | WORTHINGTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43085-2316
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-601-6272
-----------------------------------------------------
Fax | 614-601-6291
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING
-----------------------------------------------------
Name | MS. PEG DUNTEMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 630-770-3800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QI0500X
-----------------------------------------------------
Taxonomy Name | Infusion Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------