Provider Demographics
NPI:1497345003
Name:VISAGE INTEGRATIVE MEDICINE, LLC
Entity Type:Organization
Organization Name:VISAGE INTEGRATIVE MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:SUSANN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUNDRETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:325-234-2181
Mailing Address - Street 1:3144 EXECUTIVE DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904-6802
Mailing Address - Country:US
Mailing Address - Phone:325-617-4594
Mailing Address - Fax:324-617-4593
Practice Address - Street 1:3144 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-6802
Practice Address - Country:US
Practice Address - Phone:325-617-4594
Practice Address - Fax:324-617-4593
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-19
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty