Provider Demographics
NPI:1518370261
Name:INTEGRATIVE WELLNESS CENTER
Entity Type:Organization
Organization Name:INTEGRATIVE WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:LOVEJOY
Authorized Official - Last Name:ROQUE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:980-223-8535
Mailing Address - Street 1:1703 DAVIE AVE
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28677-3521
Mailing Address - Country:US
Mailing Address - Phone:980-223-8535
Mailing Address - Fax:980-223-8585
Practice Address - Street 1:1703 DAVIE AVE
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-3521
Practice Address - Country:US
Practice Address - Phone:980-223-8535
Practice Address - Fax:980-223-8585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-10
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9500440207V00000X
NC161312363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty