1407192107 NPI number — TOTAL INTEGRATED WELLNESS, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407192107 NPI number — TOTAL INTEGRATED WELLNESS, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TOTAL INTEGRATED WELLNESS, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407192107
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/27/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4600 KIETZKE LN
Provider Second Line Business Mailing Address:
M 249
Provider Business Mailing Address City Name:
RENO
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89502-5033
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
775-825-3625
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4600 KIETZKE LN
Provider Second Line Business Practice Location Address:
M 249
Provider Business Practice Location Address City Name:
RENO
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89502-5033
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
775-825-3625
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/27/2012

Additional Information

Authorized Official

Authorized Official Last Name:
JENISON
Authorized Official First Name:
ANDREW
Authorized Official Middle Name:
WILLIAM
Authorized Official Title or Position:
PRESEDENT
Authorized Official Telephone Number:
775-825-3625

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  B01357 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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