Provider Demographics
NPI:1760796601
Name:INNOVATIVE HEALTH AND WELLNESS LLC
Entity Type:Organization
Organization Name:INNOVATIVE HEALTH AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:ORLANDO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:770-926-4646
Mailing Address - Street 1:295 MOLLY LN
Mailing Address - Street 2:SUITE 150
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-3760
Mailing Address - Country:US
Mailing Address - Phone:770-926-4646
Mailing Address - Fax:770-966-8870
Practice Address - Street 1:295 MOLLY LANE
Practice Address - Street 2:SUITE 150
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-6508
Practice Address - Country:US
Practice Address - Phone:770-926-4646
Practice Address - Fax:770-966-8870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-03
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA5357111N00000X
GA33179207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202G701390Medicare PIN