Basic Information
| Provider Information | |||||||||
| NPI: | 1265862676 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INNOVATIVE HEALTH AND WELLNESS CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 297 LAKE HAVASU AVE S | ||||||||
| Address2: | 200 | ||||||||
| City: | LAKE HAVASU CITY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 864036526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9288547666 | ||||||||
| FaxNumber: | 9288547660 | ||||||||
| Practice Location | |||||||||
| Address1: | 297 LAKE HAVASU AVE S | ||||||||
| Address2: | 200 | ||||||||
| City: | LAKE HAVASU CITY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 864036526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9288547666 | ||||||||
| FaxNumber: | 9288547660 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2013 | ||||||||
| LastUpdateDate: | 11/21/2013 | ||||||||
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| AuthorizedOfficialLastName: | TILGNER | ||||||||
| AuthorizedOfficialFirstName: | SUMMER | ||||||||
| AuthorizedOfficialMiddleName: | YVONNE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9288547666 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | FNP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WG0000X | 13-00030589 | AZ | Y | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | General Practice |
No ID Information.