Provider Demographics
NPI:1316582042
Name:MAIN LINE INNTEGRATIVE AND FUNCTIONAL MEDICINE
Entity Type:Organization
Organization Name:MAIN LINE INNTEGRATIVE AND FUNCTIONAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:LORI
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:KALIE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:484-254-6186
Mailing Address - Street 1:45 E CITY AVE
Mailing Address - Street 2:
Mailing Address - City:BALA CYNWYD
Mailing Address - State:PA
Mailing Address - Zip Code:19004-2421
Mailing Address - Country:US
Mailing Address - Phone:484-254-6186
Mailing Address - Fax:202-891-4747
Practice Address - Street 1:43 LE FORGE CT
Practice Address - Street 2:
Practice Address - City:CHESTERBROOK
Practice Address - State:PA
Practice Address - Zip Code:19087-1223
Practice Address - Country:US
Practice Address - Phone:484-254-6186
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-18
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN1001XChiropractic ProvidersChiropractorNutritionGroup - Single Specialty