Provider Demographics
NPI:1346656345
Name:INTEGRATIVE PHYSICAL MEDICINE OF WINTER HAVEN LLC
Entity Type:Organization
Organization Name:INTEGRATIVE PHYSICAL MEDICINE OF WINTER HAVEN LLC
Other - Org Name:INTEGRATIVE PHYSICAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:
Authorized Official - Last Name:OTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-977-3434
Mailing Address - Street 1:7494 CYPRESS GARDENS BLVD
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33884
Mailing Address - Country:US
Mailing Address - Phone:407-977-3434
Mailing Address - Fax:
Practice Address - Street 1:7494 CYPRESS GARDENS BLVD
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33884
Practice Address - Country:US
Practice Address - Phone:407-977-3434
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INTEGRATIVE PHYSICAL MEDICINE HOLDING LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-07-10
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty