Provider Demographics
NPI:1417294174
Name:ENTEGRATIVE OTOLARYNGOLOGY PC
Entity Type:Organization
Organization Name:ENTEGRATIVE OTOLARYNGOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/CEO
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:KYLE
Authorized Official - Last Name:GAMBRELL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:267-456-4848
Mailing Address - Street 1:1144 SONOMA AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4812
Mailing Address - Country:US
Mailing Address - Phone:707-775-0775
Mailing Address - Fax:
Practice Address - Street 1:1144 SONOMA AVE STE 101
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4812
Practice Address - Country:US
Practice Address - Phone:707-775-0775
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-14
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC3527438207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic SurgeryGroup - Single Specialty