NPIMap

Organization Active NPI

Integrated Medical Wellness Center, LLC

  • Multi-Specialty Clinic/Center
  • Peoria, AZ
National Provider Identifier
1194335802
Registry record updated Aug 23, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Multi-Specialty Clinic/CenterTaxonomy code 261QM1300X
Legal business name
INTEGRATED MEDICAL WELLNESS CENTER, LLC
Practice address
10184 W Happy Valley Pkwy Ste 180
Peoria, AZ 85383-1254
Phone
(480) 289-8464
NPI assigned
Aug 6, 2020
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 23, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Andre Dreval
Title
Managing Member
Phone
(602) 400-2800

Specialties & licenses 6

Specialty (taxonomy)CodeLicenseStatePrimary
Allergy & Immunology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207K00000X
Pulmonary Disease PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207RP1001X
Clinic/Center 261Q00000X
Infusion Therapy Clinic/Center 261QI0500X
Mental Health Clinic/Center (Including Community Mental Health Center) 261QM0801X
Multi-Specialty Clinic/Center 261QM1300X Primary

Addresses

Primary practice location

10184 W Happy Valley Pkwy Ste 180
Peoria, AZ 85383-1254

Mailing address

10184 W Happy Valley Pkwy Ste 180
Peoria, AZ 85383-1254

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AZ

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20201118003223 AZ Part B Supplier - Clinic/Group Practice 9537570726 Receives reassigned benefits from 2 practitioners
Practice locations: Peoria, AZ

National Provider Directory

National Provider Directory

Locations

10184 W Happy Valley Pkwy
Ste 180
Peoria, AZ 85383
Phone (623) 322-5992

Practitioners & affiliated clinicians

Practitioners 7

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1596672000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598140800000",
    "number": "1194335802",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "10184 W HAPPY VALLEY PKWY STE 180",
            "city": "PEORIA",
            "state": "AZ",
            "postal_code": "853831254"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "10184 W HAPPY VALLEY PKWY STE 180",
            "city": "PEORIA",
            "state": "AZ",
            "postal_code": "853831254",
            "telephone_number": "480-289-8464"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "INTEGRATED MEDICAL WELLNESS CENTER, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-08-06",
        "last_updated": "2020-08-23",
        "certification_date": "2020-08-23",
        "status": "A",
        "authorized_official_last_name": "DREVAL",
        "authorized_official_first_name": "ANDRE",
        "authorized_official_title_or_position": "MANAGING MEMBER",
        "authorized_official_telephone_number": "602-400-2800"
    },
    "taxonomies": [
        {
            "code": "207K00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Allergy & Immunology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207RP1001X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine, Pulmonary Disease",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QI0500X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Infusion Therapy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QM0801X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Mental Health (Including Community Mental Health Center)",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QM1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Multi-Specialty",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Peoria, AZ

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 23, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.