Provider Demographics
NPI:1619330388
Name:WELLNESS INTEGRATIVE, PLC
Entity Type:Organization
Organization Name:WELLNESS INTEGRATIVE, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIVYR
Authorized Official - Middle Name:
Authorized Official - Last Name:DERAKHSHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-318-6910
Mailing Address - Street 1:1207 W 16TH ST STE B
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-4597
Mailing Address - Country:US
Mailing Address - Phone:928-318-6310
Mailing Address - Fax:928-328-1056
Practice Address - Street 1:1207 W 16TH ST STE B
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-4597
Practice Address - Country:US
Practice Address - Phone:928-318-6310
Practice Address - Fax:928-328-1056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-31
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty