Provider Demographics
NPI:1417270521
Name:INTEGRATIVE SPINE & BODY MEDICINE
Entity Type:Organization
Organization Name:INTEGRATIVE SPINE & BODY MEDICINE
Other - Org Name:WHOLENESS IN MOTION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ISRAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:SOSTRIN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:503-327-4756
Mailing Address - Street 1:5909 SE DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-1470
Mailing Address - Country:US
Mailing Address - Phone:503-231-3633
Mailing Address - Fax:503-234-2367
Practice Address - Street 1:5909 SE DIVISION ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-1470
Practice Address - Country:US
Practice Address - Phone:503-231-3633
Practice Address - Fax:503-234-2367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-03
Last Update Date:2015-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR208100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty