Provider Demographics
NPI:1619792256
Name:INTEGRATIVE MEDICINE & WELLNESS, INC
Entity type:Organization
Organization Name:INTEGRATIVE MEDICINE & WELLNESS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIYA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOURGET
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-863-3029
Mailing Address - Street 1:42619 STREAMLET SQ
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147-7256
Mailing Address - Country:US
Mailing Address - Phone:703-863-3029
Mailing Address - Fax:877-409-1647
Practice Address - Street 1:42619 STREAMLET SQ
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-7256
Practice Address - Country:US
Practice Address - Phone:703-863-3029
Practice Address - Fax:877-409-1647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-19
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No202D00000XAllopathic & Osteopathic PhysiciansIntegrative MedicineGroup - Multi-Specialty