=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679359079
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INNOVATIVE WELLNESS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/01/2023
-----------------------------------------------------
Last Update Date | 09/01/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2206 CURLEW RD
-----------------------------------------------------
City | PALM HARBOR
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34683-6823
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-390-1800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 29250 US HIGHWAY 19 N LOT 40
-----------------------------------------------------
City | CLEARWATER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33761-2169
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-390-1800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ACUPUNCTURE PHYSICIAN
-----------------------------------------------------
Name | DIANE R SARRA
-----------------------------------------------------
Credential | DOM
-----------------------------------------------------
Telephone | 239-390-1800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------