Provider Demographics
NPI:1689428476
Name:WELLPOINT INTEGRATIVE CARE PA
Entity type:Organization
Organization Name:WELLPOINT INTEGRATIVE CARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RADISLAV
Authorized Official - Middle Name:
Authorized Official - Last Name:KATS
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:917-892-9224
Mailing Address - Street 1:1850 S OCEAN DR APT 1709
Mailing Address - Street 2:
Mailing Address - City:HALLANDALE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33009-7680
Mailing Address - Country:US
Mailing Address - Phone:917-892-9224
Mailing Address - Fax:
Practice Address - Street 1:1850 S OCEAN DR APT 1709
Practice Address - Street 2:
Practice Address - City:HALLANDALE BEACH
Practice Address - State:FL
Practice Address - Zip Code:33009-7680
Practice Address - Country:US
Practice Address - Phone:917-892-9224
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-16
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty