Provider Demographics
NPI:1194446237
Name:INNOVATIVE WELLNESS CENTERS LLC
Entity type:Organization
Organization Name:INNOVATIVE WELLNESS CENTERS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:MS
Authorized Official - First Name:PEG
Authorized Official - Middle Name:
Authorized Official - Last Name:DUNTEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-770-3800
Mailing Address - Street 1:7100 N HIGH STREET
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WORTHINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43085-2316
Mailing Address - Country:US
Mailing Address - Phone:614-601-6272
Mailing Address - Fax:614-601-6291
Practice Address - Street 1:7100 N HIGH STREET
Practice Address - Street 2:SUITE 201
Practice Address - City:WORTHINGTON
Practice Address - State:OH
Practice Address - Zip Code:43085-2316
Practice Address - Country:US
Practice Address - Phone:614-601-6272
Practice Address - Fax:614-601-6291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-07
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health