Provider Demographics
NPI:1689701856
Name:INTEGRATIVE MANUAL THERAPY & WELLNESS
Entity Type:Organization
Organization Name:INTEGRATIVE MANUAL THERAPY & WELLNESS
Other - Org Name:NORFOLK INTEGRATIVE MANUAL THERAPY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRYSIA
Authorized Official - Middle Name:
Authorized Official - Last Name:WITKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:757-216-4151
Mailing Address - Street 1:350 W. 22ND ST.
Mailing Address - Street 2:SUITE 108
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23517-2117
Mailing Address - Country:US
Mailing Address - Phone:757-216-4151
Mailing Address - Fax:757-216-4152
Practice Address - Street 1:350 W. 22ND ST.
Practice Address - Street 2:SUITE 108
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23517-2117
Practice Address - Country:US
Practice Address - Phone:757-216-4151
Practice Address - Fax:757-216-4152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC08824Medicare PIN