Provider Demographics
NPI:1376159178
Name:INTEGRA THERAPEUTIC MASSAGE, LLC
Entity Type:Organization
Organization Name:INTEGRA THERAPEUTIC MASSAGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DARLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:TAN
Authorized Official - Suffix:
Authorized Official - Credentials:ESQ
Authorized Official - Phone:904-612-4588
Mailing Address - Street 1:8257 SEVEN MILE DR
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-3132
Mailing Address - Country:US
Mailing Address - Phone:904-612-4588
Mailing Address - Fax:
Practice Address - Street 1:1871 WELLS RD STE 300
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-2350
Practice Address - Country:US
Practice Address - Phone:904-612-4588
Practice Address - Fax:904-260-3011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-17
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT10897OtherSTATE OF FLORIDA DEPARTMENT OF HEALTH
FL1174800221Medicaid
FL1285070532Medicaid
FLPT6934OtherSTATE OF FLORIDA DEPARTMENT OF HEALTH
FLPT8535OtherSTATE OF FLORIDA DEPARTMENT OF HEALTH
FLPTA27875OtherSTATE OF FLORIDA DEPARTMENT OF HEALTH