Provider Demographics
NPI:1407042807
Name:ALACHUA INTEGRATIVE MEDICINE, INC
Entity Type:Organization
Organization Name:ALACHUA INTEGRATIVE MEDICINE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CONCEICAO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-418-1234
Mailing Address - Street 1:14804 NW 140TH ST
Mailing Address - Street 2:
Mailing Address - City:ALACHUA
Mailing Address - State:FL
Mailing Address - Zip Code:32615-6276
Mailing Address - Country:US
Mailing Address - Phone:386-418-1234
Mailing Address - Fax:386-418-8203
Practice Address - Street 1:14804 NW 140TH ST
Practice Address - Street 2:
Practice Address - City:ALACHUA
Practice Address - State:FL
Practice Address - Zip Code:32615-6276
Practice Address - Country:US
Practice Address - Phone:386-418-1234
Practice Address - Fax:386-418-8203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-19
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1557262363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK2496Medicare PIN