=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730206954
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTEGRATIVE WELLNESS CENTERS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2007
-----------------------------------------------------
Last Update Date | 09/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 906 POND VIEW RD
-----------------------------------------------------
City | RIVERHEAD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11901-2656
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-722-2246
-----------------------------------------------------
Fax | 631-727-8112
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 906 POND VIEW RD
-----------------------------------------------------
City | RIVERHEAD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11901-2656
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-722-2246
-----------------------------------------------------
Fax | 631-727-8112
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY
-----------------------------------------------------
Name | DR. CHRIS G NELSON
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 631-722-2246
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | X0109951
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number | 4812
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------