Provider Demographics
NPI:1689745341
Name:OFFICE OF INTEGRATIVE MEDICINE, INC.
Entity Type:Organization
Organization Name:OFFICE OF INTEGRATIVE MEDICINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:R
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-366-6244
Mailing Address - Street 1:PO BOX 976
Mailing Address - Street 2:
Mailing Address - City:SAINT HELENS
Mailing Address - State:OR
Mailing Address - Zip Code:97051-0976
Mailing Address - Country:US
Mailing Address - Phone:503-366-6244
Mailing Address - Fax:503-366-6246
Practice Address - Street 1:525 N COLUMBIA RIVER HWY
Practice Address - Street 2:
Practice Address - City:SAINT HELENS
Practice Address - State:OR
Practice Address - Zip Code:97051-1226
Practice Address - Country:US
Practice Address - Phone:503-366-6244
Practice Address - Fax:503-366-6246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2009-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR125757Medicaid
OR865437000OtherBLUE CROSS
ORR133488Medicare PIN