Provider Demographics
NPI:1679921415
Name:INTEGRATIVE SPORTS MEDICINE AND CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:INTEGRATIVE SPORTS MEDICINE AND CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GEOFF
Authorized Official - Middle Name:
Authorized Official - Last Name:RUDY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:415-420-9504
Mailing Address - Street 1:601 NW 22ND CT
Mailing Address - Street 2:
Mailing Address - City:WILTON MANORS
Mailing Address - State:FL
Mailing Address - Zip Code:33311-3741
Mailing Address - Country:US
Mailing Address - Phone:415-420-9504
Mailing Address - Fax:
Practice Address - Street 1:3305 RICE ST
Practice Address - Street 2:
Practice Address - City:COCONUT GROVE
Practice Address - State:FL
Practice Address - Zip Code:33133-5216
Practice Address - Country:US
Practice Address - Phone:305-792-8393
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-02
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 11861111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty