Provider Demographics
NPI:1760738413
Name:NUTRITION BASED INTEGRATIVE MEDICINE
Entity Type:Organization
Organization Name:NUTRITION BASED INTEGRATIVE MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:DANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:916-564-3300
Mailing Address - Street 1:9115 YELLOW FLOWER PL
Mailing Address - Street 2:
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-6563
Mailing Address - Country:US
Mailing Address - Phone:916-564-3300
Mailing Address - Fax:916-927-1831
Practice Address - Street 1:758 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-6703
Practice Address - Country:US
Practice Address - Phone:916-564-3300
Practice Address - Fax:916-927-1831
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-31
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A10508207QA0505X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty