Provider Demographics
NPI:1083727994
Name:INTEGRATED MEDICINE AND CHIROPRACTIC REGENERATION CENTER
Entity Type:Organization
Organization Name:INTEGRATED MEDICINE AND CHIROPRACTIC REGENERATION CENTER
Other - Org Name:IMAC REGENERATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGEMENT
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:W
Authorized Official - Last Name:BRAME
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:270-554-5114
Mailing Address - Street 1:2725 JAMES SANDERS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-8401
Mailing Address - Country:US
Mailing Address - Phone:270-554-5114
Mailing Address - Fax:270-554-5021
Practice Address - Street 1:2725 JAMES SANDERS BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-8401
Practice Address - Country:US
Practice Address - Phone:270-554-5114
Practice Address - Fax:270-554-5021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5134111N00000X
KY36051207T00000X
KY002302225100000X
225X00000X, 363L00000X, 363L00000X
KY4456111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY6655650001Medicare NSC
00436Medicare UPIN
U71886Medicare UPIN