1265862676 NPI number — INNOVATIVE HEALTH AND WELLNESS CENTER

Table of content: (NPI 1265862676)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265862676 NPI number — INNOVATIVE HEALTH AND WELLNESS CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INNOVATIVE HEALTH AND WELLNESS CENTER
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:
1265862676
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/21/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
297 LAKE HAVASU AVE S
Provider Second Line Business Mailing Address:
200
Provider Business Mailing Address City Name:
LAKE HAVASU CITY
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86403-6526
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-854-7666
Provider Business Mailing Address Fax Number:
928-854-7660

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
297 LAKE HAVASU AVE S
Provider Second Line Business Practice Location Address:
200
Provider Business Practice Location Address City Name:
LAKE HAVASU CITY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86403-6526
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-854-7666
Provider Business Practice Location Address Fax Number:
928-854-7660
Provider Enumeration Date:
11/21/2013

Additional Information

Authorized Official

Authorized Official Last Name:
TILGNER
Authorized Official First Name:
SUMMER
Authorized Official Middle Name:
YVONNE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
928-854-7666

Provider Taxonomy Codes

  • Taxonomy code: 163WG0000X , with the licence number:  13-00030589 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com