Provider Demographics
NPI:1578934600
Name:INTEGRATIVE NEUROLOGY , PLLC
Entity Type:Organization
Organization Name:INTEGRATIVE NEUROLOGY , PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-765-5386
Mailing Address - Street 1:5417 WHITTAKER RD
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-9751
Mailing Address - Country:US
Mailing Address - Phone:734-765-5386
Mailing Address - Fax:734-480-1818
Practice Address - Street 1:35519 23 MILE RD
Practice Address - Street 2:
Practice Address - City:NEW BALTIMORE
Practice Address - State:MI
Practice Address - Zip Code:48047-3603
Practice Address - Country:US
Practice Address - Phone:586-214-5495
Practice Address - Fax:734-480-1818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-15
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301087670174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1104081397Medicaid