Provider Demographics
NPI:1609241934
Name:INNVIGORATE INTEGRATIVE WELLNESS INSTITUTE
Entity Type:Organization
Organization Name:INNVIGORATE INTEGRATIVE WELLNESS INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:P
Authorized Official - Last Name:RATHVON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-473-9768
Mailing Address - Street 1:14 MONARCH BAY PLZ
Mailing Address - Street 2:STE 118
Mailing Address - City:MONARCH BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92629-3467
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7626 E SADDLEHILL TRL
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92869-2311
Practice Address - Country:US
Practice Address - Phone:206-473-9768
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-11
Last Update Date:2015-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA300340AN261QM0850X, 261QR0405X, 320800000X, 324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness