1548384100 NPI number — INTEGRATIVE MEDICINE CENTER

Table of content: (NPI 1548384100)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548384100 NPI number — INTEGRATIVE MEDICINE CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTEGRATIVE MEDICINE CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1548384100
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9371 CYPRESS LAKE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33919-4939
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-274-3413
Provider Business Mailing Address Fax Number:
239-415-8661

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9371 CYPRESS LAKE DR STE 13
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT MYERS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33919-4995
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-274-3413
Provider Business Practice Location Address Fax Number:
239-415-8661
Provider Enumeration Date:
03/19/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
OKONSKI
Authorized Official First Name:
LIDIA
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
239-274-3413

Provider Taxonomy Codes

  • Taxonomy code: 146D00000X , with the licence number:  ME 36300 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 171100000X , with the licence number: 001033 AP , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: ME 36300 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: PIN . This is a "D 79863" identifier . This identifiers is of the category "OTHER".
  • Identifier: 11490 . This is a "BLUE CROSS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 001033 AP . This is a "ACUPUNCTUE LICENSE" identifier . This identifiers is of the category "OTHER".
  • Identifier: CO 434 . This is a "BLUE CROSS" identifier . This identifiers is of the category "OTHER".