=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730890682
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INCITE HEALTH AND WELLNESS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2022
-----------------------------------------------------
Last Update Date | 12/12/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20470 N LAKE PLEASANT RD STE 109
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85382-9708
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-628-6216
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5947 W STRAIGHT ARROW LN
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85083-6568
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-628-6216
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, OPERATOR
-----------------------------------------------------
Name | BRIAN MCINTOSH
-----------------------------------------------------
Credential | PA-C
-----------------------------------------------------
Telephone | 623-628-6216
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------