1376159178 NPI number — INTEGRA THERAPEUTIC MASSAGE, LLC

Table of content: (NPI 1376159178)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376159178 NPI number — INTEGRA THERAPEUTIC MASSAGE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTEGRA THERAPEUTIC MASSAGE, LLC
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:
1376159178
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/18/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8257 SEVEN MILE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PONTE VEDRA BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32082-3132
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-612-4588
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1871 WELLS RD STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORANGE PARK
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32073-2350
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-612-4588
Provider Business Practice Location Address Fax Number:
904-260-3011
Provider Enumeration Date:
09/17/2020

Additional Information

Authorized Official

Authorized Official Last Name:
TAN
Authorized Official First Name:
DARLENE
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
904-612-4588

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PT10897 . This is a "STATE OF FLORIDA DEPARTMENT OF HEALTH" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1174800221 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1285070532 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: PT6934 . This is a "STATE OF FLORIDA DEPARTMENT OF HEALTH" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: PT8535 . This is a "STATE OF FLORIDA DEPARTMENT OF HEALTH" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: PTA27875 . This is a "STATE OF FLORIDA DEPARTMENT OF HEALTH" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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