Provider Demographics
NPI:1619946241
Name:INTEGRATED MEDICAL CENTRE OF BONITA SPRINGS INC
Entity Type:Organization
Organization Name:INTEGRATED MEDICAL CENTRE OF BONITA SPRINGS INC
Other - Org Name:ACCIDENT AND INJURY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER CLINIC DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:GENDRON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:239-947-1177
Mailing Address - Street 1:28315 S TAMIAMI TRAIL
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34134
Mailing Address - Country:US
Mailing Address - Phone:239-947-1177
Mailing Address - Fax:239-947-6399
Practice Address - Street 1:28315 S TAMIAMI TRAIL
Practice Address - Street 2:SUITE 101
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34134
Practice Address - Country:US
Practice Address - Phone:239-947-1177
Practice Address - Fax:239-947-6399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-16
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0005999111N00000X
FLCH0005870171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty