Provider Demographics
NPI:1760175723
Name:INTEGRATED WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:INTEGRATED WELLNESS CENTER LLC
Other - Org Name:RT BUILDERS LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RAVIKULASINGHAM
Authorized Official - Middle Name:
Authorized Official - Last Name:THURAISINGAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:650-847-8861
Mailing Address - Street 1:5523 S JOLLY ROGER RD
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-2118
Mailing Address - Country:US
Mailing Address - Phone:650-847-8861
Mailing Address - Fax:602-844-2525
Practice Address - Street 1:2316 W NORTHERN AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-4935
Practice Address - Country:US
Practice Address - Phone:602-838-7799
Practice Address - Fax:602-844-2525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-26
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center