Provider Demographics
NPI:1093239469
Name:INTEGRITY EXTENDED HEALTHCARE LLC
Entity Type:Organization
Organization Name:INTEGRITY EXTENDED HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:PALLAKI
Authorized Official - Middle Name:D
Authorized Official - Last Name:RAVI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-660-5830
Mailing Address - Street 1:PO BOX 10
Mailing Address - Street 2:
Mailing Address - City:EUBANK
Mailing Address - State:KY
Mailing Address - Zip Code:42567-0010
Mailing Address - Country:US
Mailing Address - Phone:248-660-5830
Mailing Address - Fax:859-224-2057
Practice Address - Street 1:308 W MAPLE AVE
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:KY
Practice Address - Zip Code:40444-1005
Practice Address - Country:US
Practice Address - Phone:248-660-5830
Practice Address - Fax:859-224-2057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-27
Last Update Date:2017-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY46290207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYMPKY.0674-00OtherMED MAL