Provider Demographics
NPI:1215030747
Name:INTEGRATIVE MEDICAL CENTER
Entity Type:Organization
Organization Name:INTEGRATIVE MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:
Authorized Official - Last Name:JAYASINGHE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:213-483-2620
Mailing Address - Street 1:1930 WILSHIRE BLVD
Mailing Address - Street 2:STE 1100
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-3605
Mailing Address - Country:US
Mailing Address - Phone:213-483-2620
Mailing Address - Fax:213-483-7918
Practice Address - Street 1:526 W 17TH ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92706-3619
Practice Address - Country:US
Practice Address - Phone:714-558-9355
Practice Address - Fax:714-558-0870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA31911207Q00000X
CAA49332207Q00000X
CAA26210207VG0400X
CAA38978208000000X
CAPA14480363A00000X
CAPA14957363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Not Answered363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0015600Medicaid
CAGR0015600Medicaid