Provider Demographics
NPI:1255478459
Name:INTEGRATED THERAPY AND DIAGNOSTICS,LLC
Entity Type:Organization
Organization Name:INTEGRATED THERAPY AND DIAGNOSTICS,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:L
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-645-0399
Mailing Address - Street 1:23077 GREENFIELD RD STE 110
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-3744
Mailing Address - Country:US
Mailing Address - Phone:248-569-3002
Mailing Address - Fax:248-569-3008
Practice Address - Street 1:23077 GREENFIELD RD STE 110
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-3744
Practice Address - Country:US
Practice Address - Phone:248-569-3002
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MID0637C261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P40780Medicare PIN