Provider Demographics
NPI:1053735803
Name:INNOVATIVE WELLNESS SOLUTIONS LLC
Entity type:Organization
Organization Name:INNOVATIVE WELLNESS SOLUTIONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:A
Authorized Official - Last Name:LEONARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:412-279-4522
Mailing Address - Street 1:1902 RIVER ROAD
Mailing Address - Street 2:
Mailing Address - City:N APOLLO
Mailing Address - State:PA
Mailing Address - Zip Code:15673
Mailing Address - Country:US
Mailing Address - Phone:724-478-5361
Mailing Address - Fax:724-479-2930
Practice Address - Street 1:1902 RIVER ROAD
Practice Address - Street 2:
Practice Address - City:APOLLO
Practice Address - State:PA
Practice Address - Zip Code:15673
Practice Address - Country:US
Practice Address - Phone:724-478-5361
Practice Address - Fax:724-479-2930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-14
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD044592E208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA=========OtherTAX ID