Provider Demographics
NPI:1386423804
Name:INTEGRATIVE MEDICINE & WELLNESS
Entity type:Organization
Organization Name:INTEGRATIVE MEDICINE & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARIYA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOURGET
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:571-659-4316
Mailing Address - Street 1:42029 BUSHCLOVER TERRACE
Mailing Address - Street 2:
Mailing Address - City:ALDIE
Mailing Address - State:VA
Mailing Address - Zip Code:20105
Mailing Address - Country:US
Mailing Address - Phone:571-659-4316
Mailing Address - Fax:866-611-2705
Practice Address - Street 1:42029 BUSHCLOVER TERRACE
Practice Address - Street 2:
Practice Address - City:ALDIE
Practice Address - State:VA
Practice Address - Zip Code:20105
Practice Address - Country:US
Practice Address - Phone:571-659-4316
Practice Address - Fax:866-611-2705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVV1662BMedicaid