Provider Demographics
NPI:1033481064
Name:INNATE WELLNESS CENTER
Entity Type:Organization
Organization Name:INNATE WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:EJUWA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-864-1657
Mailing Address - Street 1:5113 AUBURNDALE AVE
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-5197
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5113 AUBURNDALE AVE
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-5197
Practice Address - Country:US
Practice Address - Phone:715-864-1657
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-07
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11959111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty