Provider Demographics
NPI:1184228413
Name:ITRUST WELLNESS GROUP THERAPEUTICS
Entity Type:Organization
Organization Name:ITRUST WELLNESS GROUP THERAPEUTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:KROZER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-520-2020
Mailing Address - Street 1:117 COMMONS WAY
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29611-3850
Mailing Address - Country:US
Mailing Address - Phone:864-520-2020
Mailing Address - Fax:864-640-4400
Practice Address - Street 1:117 COMMONS WAY
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29611-3850
Practice Address - Country:US
Practice Address - Phone:864-520-2020
Practice Address - Fax:864-640-4400
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ITRUST WELLNESS GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-11-27
Last Update Date:2020-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP9535Medicaid