Provider Demographics
NPI:1700204302
Name:INTEGRATIVE MODALITY, INC
Entity Type:Organization
Organization Name:INTEGRATIVE MODALITY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LORRAINE
Authorized Official - Middle Name:D
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:954-816-6703
Mailing Address - Street 1:12555 ORANGE DR
Mailing Address - Street 2:#4079
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33330-4304
Mailing Address - Country:US
Mailing Address - Phone:954-862-1720
Mailing Address - Fax:
Practice Address - Street 1:12555 ORANGE DR
Practice Address - Street 2:#4079
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33330-4304
Practice Address - Country:US
Practice Address - Phone:954-862-1720
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-01
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL28002333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy