Provider Demographics
NPI:1821505462
Name:INTEGRATIVE WELLNESS & COSMETICS, INC
Entity Type:Organization
Organization Name:INTEGRATIVE WELLNESS & COSMETICS, INC
Other - Org Name:STUDIO 17 COSMETICS & WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIZA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-301-4344
Mailing Address - Street 1:65 WINDSOR DR
Mailing Address - Street 2:
Mailing Address - City:PINE BROOK
Mailing Address - State:NJ
Mailing Address - Zip Code:07058-9757
Mailing Address - Country:US
Mailing Address - Phone:973-908-3368
Mailing Address - Fax:
Practice Address - Street 1:601 9TH ST
Practice Address - Street 2:
Practice Address - City:HOBOKEN
Practice Address - State:NJ
Practice Address - Zip Code:07030-6428
Practice Address - Country:US
Practice Address - Phone:201-301-4344
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-04
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA09325400261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ25MA09325400OtherMEDICAL LICENSE