Provider Demographics
NPI:1639734213
Name:IDEAL WELLNESS FAMILY PRACTICE, PC
Entity Type:Organization
Organization Name:IDEAL WELLNESS FAMILY PRACTICE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:AMANDA
Authorized Official - Last Name:ORNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:609-731-3478
Mailing Address - Street 1:511 BYLER CIR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17042-4866
Mailing Address - Country:US
Mailing Address - Phone:609-731-3478
Mailing Address - Fax:
Practice Address - Street 1:701 LEON AVE
Practice Address - Street 2:
Practice Address - City:PALMYRA
Practice Address - State:PA
Practice Address - Zip Code:17078-3554
Practice Address - Country:US
Practice Address - Phone:717-256-1820
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-08
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care