Provider Demographics
NPI:1609211648
Name:INTEGRATIVE WELLNESS MEDICAL GROUP
Entity type:Organization
Organization Name:INTEGRATIVE WELLNESS MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KERRIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MOOTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-444-0111
Mailing Address - Street 1:125 N ACACIA
Mailing Address - Street 2:SUITE 111
Mailing Address - City:SOLANA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92075
Mailing Address - Country:US
Mailing Address - Phone:858-444-0111
Mailing Address - Fax:858-794-2722
Practice Address - Street 1:125 N ACACIA AVE
Practice Address - Street 2:SUITE 111
Practice Address - City:SOLANA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92075-1165
Practice Address - Country:US
Practice Address - Phone:858-444-0111
Practice Address - Fax:858-794-2722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-03
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA30803111N00000X
CA104552207Q00000X
CAA96446207RE0101X
CAA1045522084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty