Provider Demographics
NPI:1811396757
Name:INTEGRATED WELLNESS CLUB
Entity type:Organization
Organization Name:INTEGRATED WELLNESS CLUB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER, LLC
Authorized Official - Prefix:MR
Authorized Official - First Name:RUSTOM
Authorized Official - Middle Name:
Authorized Official - Last Name:ALI
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:480-703-4227
Mailing Address - Street 1:1968 MESQUITE AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-5729
Mailing Address - Country:US
Mailing Address - Phone:480-703-4227
Mailing Address - Fax:
Practice Address - Street 1:1968 MESQUITE AVE
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5729
Practice Address - Country:US
Practice Address - Phone:480-703-4227
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-16
Last Update Date:2014-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174H00000XOther Service ProvidersHealth EducatorGroup - Single Specialty