Provider Demographics
NPI:1710571880
Name:INTEGRATED MEDICINE AND WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:INTEGRATED MEDICINE AND WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:M
Authorized Official - Last Name:KOVACH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:410-697-3566
Mailing Address - Street 1:959 ANNAPOLIS RD
Mailing Address - Street 2:
Mailing Address - City:GAMBRILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21054-1028
Mailing Address - Country:US
Mailing Address - Phone:410-697-3566
Mailing Address - Fax:410-697-3567
Practice Address - Street 1:959 ANNAPOLIS RD
Practice Address - Street 2:
Practice Address - City:GAMBRILLS
Practice Address - State:MD
Practice Address - Zip Code:21054-1028
Practice Address - Country:US
Practice Address - Phone:410-697-3566
Practice Address - Fax:410-697-3567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-01
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty