Provider Demographics
NPI:1104580943
Name:INTEGRATED MEDICAL AND WELLNESS CLINIC OF MISSISSIPPI LLC
Entity type:Organization
Organization Name:INTEGRATED MEDICAL AND WELLNESS CLINIC OF MISSISSIPPI LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, AUTHORIZED OFFICIAL
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:F
Authorized Official - Last Name:ROWE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-248-0561
Mailing Address - Street 1:2556 MARCIA CT
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39531-2352
Mailing Address - Country:US
Mailing Address - Phone:228-248-0561
Mailing Address - Fax:228-248-0562
Practice Address - Street 1:212 DRAPERTON CT
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-3905
Practice Address - Country:US
Practice Address - Phone:769-300-9040
Practice Address - Fax:769-300-9055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-27
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty